A patient reports to the clinic nurse that she has not had a period in over 12 weeks, she is tired, and her breasts are sore all of the time. The patient's urine test is positive for hCG. What is the best nursing action related to this information?
a. Ask the patient if she has had any nausea or vomiting in the morning.
b. Schedule the patient to be seen by a health care provider within the next 4 weeks.
c. Send the patient to the maternity screening area of the clinic for a routine ultrasound.
d. Determine if there are any factors that might prohibit her from seeking medical care.
ANS: D
The patient has presumptive and probable indications of pregnancy. However, she has not sought out health care until late in the first or early in the second trimester. The nurse must assess for barriers to seeking health care, physical or emotional, because regular prenatal care is key to a positive pregnancy outcome. Asking if the patient has nausea or vomiting will only add to the list of presumptive signs of pregnancy, and this information will not add to the assessment data to determine whether the client is pregnant. The patient needs to see a health care provider before the next 4 weeks because she is late in seeking early prenatal care. Ultrasounds must be prescribed by a health care provider and ordering one is not in the nurse's scope of practice.
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A) True B) False
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