A young adolescent is in active labor but did not know that she was pregnant. What is the most important nursing action?
1. Assess blood pressure and check for proteinuria.
2. Obtain a Social Services referral to discuss adoption.
3. Determine who might be the father of the baby for paternity testing.
4. Ask the client what kind of birthing experience she would like to have.
1
Explanation:
1. Preeclampsia is more common among adolescents than in young adults, and it is potentially life threatening to both the mother and fetus. This assessment is the highest priority.
2. During labor is an inappropriate time to discuss adoption or parenting. Wait until after the birth to have this discussion when dealing with an adolescent who did not know she was pregnant prior to the onset of labor.
3. Paternity testing is a lower priority than the physiologic well-being of the client and fetus.
4. A client with a previously undiagnosed pregnancy is unlikely to have given any thought to childbearing preferences.
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