Question

A community health nurse visits a family in which a 16-year-old unmarried daughter is pregnant with her first child and is at 32-weeks gestation. The client tells the nurse that she has been having intermittent back pain since the night before. What is the priority nursing intervention?

1) Ask the client's mother to call an ambulance for transport to the hospital immediately.
2) Determine what physical activities the client has performed for the past 24 hours.
3) Teach the client if she has experienced any recent changes in vaginal discharge.

Answer 1

The priority nursing intervention is to assess for additional signs of preterm labor since intermittent back pain could indicate impending labor. The nurse should check changes in vaginal discharge, uterine contractions, and any other symptoms before deciding further actions, including whether to call an ambulance.

Step-by-step explanation:

The priority nursing intervention for a 16-year-old at 32-weeks gestation experiencing intermittent back pain is to determine if she's experiencing preterm labor. Since back pain can be a symptom of labor, the nurse should assess for additional signs of preterm labor, such as changes in vaginal discharge, uterine contractions, and any other associated symptoms like abdominal cramping or pelvic pressure. The decision to call for an ambulance would depend on the assessment findings indicating imminent birth or complications.

Back pain is common in late pregnancy due to the additional weight and changes in posture pregnant women often experience. As the uterus expands, it can strain the back muscles and ligaments, leading to discomfort. The 16-year-old's complaint of back pain necessitates a careful evaluation to rule out preterm labor as it can lead to complications for both mother and child. If the nurse finds any indication of preterm labor, immediate medical attention would be required to manage the condition appropriately.