A young adolescent is transferred to the labor and delivery unit from the emergency department. The patient is in active labor, but did not know 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 patient 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 patient and fetus.
Rationale 2: A patient with a previously undiagnosed pregnancy is unlikely to have given any thought to childbearing preferences.
Rationale 3: Preeclampsia 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.
Rationale 4: It would be inappropriate to discuss adoption or parenting during labor, especially with an adolescent who did not know she was pregnant prior to the onset of labor. The nurse should wait until after the birth to have this discussion.
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