Antepartum Care
UNFOLDING Reasoning
Anne Jones, 17 years old
Primary Concept
Reproduction
Interrelated Concepts (In order of emphasis)
1. Nutrition
2. Patient Education
3. Stress
4. Coping
5. Clinical Judgment
6. Communication
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
• Management of Care 17-23% ✓
• Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12% ✓
Psychosocial Integrity 6-12% ✓
Physiological Integrity
• Basic Care and Comfort 6-12% ✓
• Pharmacological and Parenteral Therapies 12-18% ✓
• Reduction of Risk Potential 9-15% ✓
• Physiological Adaptation 11-17% ✓
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.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Clinical Significance:
Problem:
1. 17-year-old female reports two missed
periods.
2. Reported some spotting last week
3. C/O breast tenderness, swelling, -These are all presumptive signs of pregnancy.
increased frequent in urination, and
a.m. nausea
4. (+) pregnancy test
5. Provider has ordered urinalysis and
pre-natal lab panel
RELEVANT Data from Social Clinical Significance:
History:
1. Senior in H/S.
2. Works in a job that requires constant
standing
3. Denies use of alcohol/nicotine & is -Patient is in stable health with no known major medical concerns
not on any prescription medications at this point. We know that she will need her nutrition and dietary
4. Reports a daily diet of poor nutritional habits addressed to successfully accommodate a growing fetus.
value She will also need a support system and education on what to
5. Does not currently have a support expect in the coming months. We’ll know more when her lab
system, as she has not informed panel comes back.
anyone of her present situation
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
UNFOLDING Reasoning
Anne Jones, 17 years old
Primary Concept
Reproduction
Interrelated Concepts (In order of emphasis)
1. Nutrition
2. Patient Education
3. Stress
4. Coping
5. Clinical Judgment
6. Communication
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
• Management of Care 17-23% ✓
• Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12% ✓
Psychosocial Integrity 6-12% ✓
Physiological Integrity
• Basic Care and Comfort 6-12% ✓
• Pharmacological and Parenteral Therapies 12-18% ✓
• Reduction of Risk Potential 9-15% ✓
• Physiological Adaptation 11-17% ✓
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.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Clinical Significance:
Problem:
1. 17-year-old female reports two missed
periods.
2. Reported some spotting last week
3. C/O breast tenderness, swelling, -These are all presumptive signs of pregnancy.
increased frequent in urination, and
a.m. nausea
4. (+) pregnancy test
5. Provider has ordered urinalysis and
pre-natal lab panel
RELEVANT Data from Social Clinical Significance:
History:
1. Senior in H/S.
2. Works in a job that requires constant
standing
3. Denies use of alcohol/nicotine & is -Patient is in stable health with no known major medical concerns
not on any prescription medications at this point. We know that she will need her nutrition and dietary
4. Reports a daily diet of poor nutritional habits addressed to successfully accommodate a growing fetus.
value She will also need a support system and education on what to
5. Does not currently have a support expect in the coming months. We’ll know more when her lab
system, as she has not informed panel comes back.
anyone of her present situation
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
