Details of Antepartum Care UNFOLDING Reasoning ; Anne Jones is a 17-year-old
History of Present Problem:
Anne Jones is a 17-year-old Caucasian teenager
... [Show More] who thinks she may be pregnant because she has missed two periods.
Her last menstrual period, she thinks, was about one month ago. She states she had a little bit of spotting last week but
didn’t have a “full period”. She complains of her breasts being tender, swollen, frequent urination, and nausea in the
morning. This is her first office visit and she is not sure why she feels so crummy but suspects she might be pregnant.
Her urine pregnancy test is positive. Her primary care provider orders a prenatal lab panel and a urinalysis.
Personal/Social History:
Anne is a senior in high school who stands on her feet while working at McDonalds after school. She drinks six colas
daily, denies alcohol use, and does not smoke. She takes no medications except for occasional acetaminophen for
headaches and ibuprofen for menstrual cramps. Anne is 5’4” (160 cm) and weighs about 105 lbs. (47.7 kg) according to
Anne. A 24-hour recall nutrition history reveals a typical day’s diet: breakfast- pop tart and can of cola; Lunch- a slice of
pizza, chocolate chip cookie, can of cola; Dinner- fried chicken, green beans, biscuit, can of cola; snacks, including
cookies and can of cola. She broke up last week with her boyfriend, and he is not aware she might be pregnant. She wants
to keep the baby but has not told her parents.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present
Problem:
Clinical Significance:
1. 17-year-old female reports two missed
periods.
2. Reported some spotting last week
3. C/O breast tenderness, swelling,
increased frequent in urination, and
a.m. nausea
4. (+) pregnancy test
5. Provider has ordered urinalysis and
pre-natal lab panel
-These are all presumptive signs of pregnancy.
RELEVANT Data from Social History: Clinical Significance:
1. Senior in H/S.
2. Works in a job that requires constant
standing
3. Denies use of alcohol/nicotine & is
not on any prescription medications
4. Reports a daily diet of poor nutritional
value
5. Does not currently have a support
system, as she has not informed
anyone of her present situation
-Patient is in stable health with no known major medical concerns
at this point. We know that she will need her nutrition and dietary
habits addressed to successfully accommodate a growing fetus.
She will also need a support system and education on what to
expect in the coming months. We’ll know more when her lab
panel comes back.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 98.6 F/37.0 C (oral) Provoking/Palliative: Breast tenderness
P: 76 (regular) Quality: Tender to touch and movement
R: 18 (regular) Region/Radiation: Both breasts
BP: 125/80 Severity: 4/10 but better if wears a bra
O2 sat: not assessed Timing: For the past couple of months
What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction
of Risk Potential/Health Promotion and Maintenance)
RELEVANT VS
Data:
Clinical Significance:
1. Temp, HR, & RR
are all within
expected/acceptabl
e ranges
2. BP is on the upper
end of acceptable
-There really is no significance to her first three VS, but her BP being on the higher
end of acceptable is mildly concerning. Considering how young she is and that she
isn’t overweight and doesn’t have any other diagnosed medical conditions, we’d like
to see that number be a little lower; especially because as she progresses further into
the pregnancy we know that BP will continue to rise. So with her current baseline,
she’s at an increased risk of having a BP that’s excessively high later on down the
line.
Current Assessment:
GENERAL
APPEARANCE:
Calm, body relaxed, no grimacing, appears to be slightly nervous, Height 5’4” (160 cm),
weight 100 lbs. (45.5 kg), 5 lbs. (2.3 kg) weight loss from pre-pregnant weight, no appetite.
BMI 18
RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong,
equal with palpation at radial, brisk cap refill
NEURO: Alert and oriented to person, place, time, and situation (x4)
HEENT: Normal cephalic, slight bleeding at gum lines. Conjunctiva of eyelids; appears pale
Chest: Breasts tender on palpation, areola darkened and occasional veins present
Abdomen: Soft; no masses, uterus palpable below the level of the symphysis pubis,
Extremities: Mild spider varicose veins on the medial aspect of the left leg, deep tendon reflexes 2+
Pelvic Exam: Vagina and cervix deep purple in color, uterus slightly enlarged, and Hagar’s sign present
What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction
of Risk Potential/Health Promotion and Maintenance)
RELEVANT Assessment Data: Clinical Significance:
1. She’s had a 5lb weight loss since
pregnancy
2. She reports some bleeding at the
gums
3. Her conjunctiva is pale
a. Breasts tender
b. Varicose veins—lower
extremity
c. Purple cervix/ + Hagar’s
sign
-Her weight lost is concerning, especially since she was so thin to
begin with. We already know she has a poor diet that lacks many of
the basic nutrients that she and her baby will need
-Bleeding of the gums is a common issue during pregnancy, however,
it’s one that needs to be addressed. She is more susceptible to plaque
buildup with leads in inflammation and bleeding. We’ll need to make
sure she focuses more on oral care as far as brushing and flossing her
teeth are concerned
-The paleness of her conjunctive makes me think we’re looking at
some anemia here, especially with the pregnancy and her nutritional
history
-The other assessment findings are expected and of no concern at this
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