A young adolescent is transferred to the Labor and Delivery unit from the Emergency Department. The client is in active labor, but did not know that she was pregnant. The most important nursing action is to:
1. Determine who might be the father of the baby for paternity testing.
2. Ask the client what kind of birthing experience she would like to have.
3. Assess blood pressure and check for proteinuria.
4. Obtain a Social Services referral to discuss adoption.
3
Rationale:
1. Paternity testing is a lower priority than the physiologic well-being of the client and fetus.
2. A client with a previously undiagnosed pregnancy is unlikely to have given any thought to childbearing preferences.
3. Pre-eclampsia is more common among adolescents than in young adults, and is potentially life-threatening to both mother and fetus. This assessment is the highest priority.
4. 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.
You might also like to view...
The Health Information Technology for Economic and Clinical Health (HITECH) encouraged implementation of electronic health records (EHR) by what means?
a. Fining facilities that did not convert to EHRs by 2015 b. Mandating that all facilities implement EHRs within the year c. Providing incentive payments to facilities that converted to EHRs d. Restricting providers' access to traditional patient health records
During a physical exam, the nurse practitioner notes that the patient's optic disk is very pale with a larger size/depth of the optic cup. At this point, they are thinking the patient may have
A) glaucoma. B) diabetes retinopathy. C) macular degeneration. D) retinal tear.
Which condition is a transient, self-limiting mood disorder that affects new mothers after childbirth?
a. Postpartum depression b. Postpartum psychosis c. Postpartum bipolar disorder d. Postpartum blues
The nurse caring for a client who is 20 weeks pregnant realizes that which of the following health issues can predispose the client to developing eclampsia?
1. Fibrocystic breast disease 2. Type 2 diabetes mellitus 3. Surgery for ruptured appendix 1 year prior 4. Treatment for vitamin D deficiency