Antepartum Care
UNFOLDING Reasoning
Anne Jones, 17 years old
History of Present Problem:
Anne Jones is a 17-year-old Caucasian teenager who thinks she may be pregnant because she has missed two periods.
Her last menstrual period, she thinks, was about one month ago. She states she had a little bit of spotting last week but
didn’t have a “full period”. She complains of her breasts being tender, swollen, frequent urination, and nausea in the
morning. This is her first office visit and she is not sure why she feels so crummy but suspects she might be pregnant.
Her urine pregnancy test is positive. Her primary care provider orders a prenatal lab panel and a urinalysis.
Personal/Social History:
Anne is a senior in high school who stands on her feet while working at McDonalds after school. She drinks six colas
daily, denies alcohol use, and does not smoke. She takes no medications except for occasional acetaminophen for
headaches and ibuprofen for menstrual cramps. Anne is 5’4” (160 cm) and weighs about 105 lbs. (47.7 kg) according to
Anne. A 24-hour recall nutrition history reveals a typical day’s diet: breakfast- pop tart and can of cola; Lunch- a slice of
pizza, chocolate chip cookie, can of cola; Dinner- fried chicken, green beans, biscuit, can of cola; snacks, including
cookies and can of cola. She broke up last week with her boyfriend, and he is not aware she might be pregnant. She wants
to keep the baby but has not told her parents.
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
, What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Two missed periods S&S of pregnancy pending confirmatory testing
Complaints of breasts being tender
and swollen.
Frequent urination.
Nausea in the morning.
Positive urine pregnancy test.
RELEVANT Data from Social History: Clinical Significance:
Senior in H/S. May face social stigmas d/t being pregnant in HS that may
Single affect mental and emotional health.
Current employment requires May be a single mom and may need assistance d/t young age.
long periods of standing. Being on her feet all day could present issues with swelling and
Drinks 6 sodas/day. fatigue.
Diet high in sugar and low Lack of well-balanced diet can be problematic for her and
nutritional value. baby’s health.
Possible lack of support system. Need to assess what her support system may look like since she
has yet to tell anyone of possible pregnancy.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 98.6 F/37.0 C (oral) Provoking/Palliative: Breast tenderness
P: 76 (regular) Quality: Tender to touch and movement
R: 18 (regular) Region/Radiation: Both breasts
BP: 125/80 Severity: 4/10 but better if wears a bra
O2 sat: not assessed Timing: For the past couple of months
How will the nurse interpret each of these findings? (Address each one)
RELEVANT VS Data: Clinical Significance:
VS WNL VS WNL, however, with BP will need to be monitored. It seems a bit high
Breast considering her current BMI so she may be a candidate for pre-eclampsia during her
tenderness pregnancy.
Tender to touch All are S&S of pregnancy
and movement.
4/10 but better if
wears a bra.
For the past
couple of months
Current Assessment:
GENERAL Calm, body relaxed, no grimacing, appears to be slightly nervous, Height 5’4” (160 cm),
APPEARANCE: weight 100 lbs. (45.5 kg), 5 lbs. (2.3 kg) weight loss from pre-pregnant weight, no appetite.
BMI 18
RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong,
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
UNFOLDING Reasoning
Anne Jones, 17 years old
History of Present Problem:
Anne Jones is a 17-year-old Caucasian teenager who thinks she may be pregnant because she has missed two periods.
Her last menstrual period, she thinks, was about one month ago. She states she had a little bit of spotting last week but
didn’t have a “full period”. She complains of her breasts being tender, swollen, frequent urination, and nausea in the
morning. This is her first office visit and she is not sure why she feels so crummy but suspects she might be pregnant.
Her urine pregnancy test is positive. Her primary care provider orders a prenatal lab panel and a urinalysis.
Personal/Social History:
Anne is a senior in high school who stands on her feet while working at McDonalds after school. She drinks six colas
daily, denies alcohol use, and does not smoke. She takes no medications except for occasional acetaminophen for
headaches and ibuprofen for menstrual cramps. Anne is 5’4” (160 cm) and weighs about 105 lbs. (47.7 kg) according to
Anne. A 24-hour recall nutrition history reveals a typical day’s diet: breakfast- pop tart and can of cola; Lunch- a slice of
pizza, chocolate chip cookie, can of cola; Dinner- fried chicken, green beans, biscuit, can of cola; snacks, including
cookies and can of cola. She broke up last week with her boyfriend, and he is not aware she might be pregnant. She wants
to keep the baby but has not told her parents.
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
, What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
Two missed periods S&S of pregnancy pending confirmatory testing
Complaints of breasts being tender
and swollen.
Frequent urination.
Nausea in the morning.
Positive urine pregnancy test.
RELEVANT Data from Social History: Clinical Significance:
Senior in H/S. May face social stigmas d/t being pregnant in HS that may
Single affect mental and emotional health.
Current employment requires May be a single mom and may need assistance d/t young age.
long periods of standing. Being on her feet all day could present issues with swelling and
Drinks 6 sodas/day. fatigue.
Diet high in sugar and low Lack of well-balanced diet can be problematic for her and
nutritional value. baby’s health.
Possible lack of support system. Need to assess what her support system may look like since she
has yet to tell anyone of possible pregnancy.
Patient Care Begins:
Current VS: P-Q-R-S-T Pain Assessment:
T: 98.6 F/37.0 C (oral) Provoking/Palliative: Breast tenderness
P: 76 (regular) Quality: Tender to touch and movement
R: 18 (regular) Region/Radiation: Both breasts
BP: 125/80 Severity: 4/10 but better if wears a bra
O2 sat: not assessed Timing: For the past couple of months
How will the nurse interpret each of these findings? (Address each one)
RELEVANT VS Data: Clinical Significance:
VS WNL VS WNL, however, with BP will need to be monitored. It seems a bit high
Breast considering her current BMI so she may be a candidate for pre-eclampsia during her
tenderness pregnancy.
Tender to touch All are S&S of pregnancy
and movement.
4/10 but better if
wears a bra.
For the past
couple of months
Current Assessment:
GENERAL Calm, body relaxed, no grimacing, appears to be slightly nervous, Height 5’4” (160 cm),
APPEARANCE: weight 100 lbs. (45.5 kg), 5 lbs. (2.3 kg) weight loss from pre-pregnant weight, no appetite.
BMI 18
RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong,
Copyright © 2019 Keith Rischer, d/b/a KeithRN.com. All Rights reserved.
