The nurse is interviewing the mother of an infant. The mother reports, "I had a difficult delivery, and my baby was born prematurely." This information should be recorded under which heading?
a. History
b. Present illness
c. Chief complaint
d. Review of systems
ANS: A
The history refers to information that relates to previous aspects of the child's health, not to the current problem. The difficult delivery and prematurity are important parts of the infant's history. The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of the present illness. The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. It should not include the birth information. The review of systems is a specific review of each body system. It does not include the premature birth but might include sequelae such as pulmonary dysfunction.
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