Mary a 17-year-old, gravida 1 para 0

Mary a 17-year-old, gravida 1 para 0 who is 39 weeks gestation and admitted to the labor room for observation. She began having contractions three hours ago at 8 to 10-minute intervals with each contraction lasting 30 seconds. She states her pain is 5/10. Her membranes are intact. On admission, a vaginal exam indicates cervical dilation is 5 cm, 80% effacement, and 0 station. After two hours of observation, her cervix is 7 cm/ 80% effacement/ +2 station and contractions are now 2 minutes apart, lasting 60 seconds and pain is 8/10. Fetal lie is longitudinal with a cephalic presentation. You have her prenatal records from her visits to the office. She is Group Beta Strep (GBS) positive and received antibiotics at 36 weeks. Her blood type is A negative. Mary’s mother is with her, and the father of the baby is not involved. She appears to be relaxed although she states she is a bit nervous. She wants a natural non-medicated birth, and her mother will help coach her. She plans on breastfeeding. She attended childbirth preparation classes with her mother. What patient history has clinical significance to the nurse and why? The most recent vital signs were: T: 98.9 F (oral) P: 84 (reg) R: 20 (reg) BP: 132/84 O2 sat: 98% on room air What patient vital signs has clinical significance to the nurse and why? GENERAL APPEARANCE: Calm, body relaxed, no grimacing, appears to be slightly anxious. RESP: Breath sounds clear with equal aeration bilaterally ant/post, non-labored respiratory effort CARDIAC: Pink, warm & dry, slight ankle edema, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial, brisk cap refill NEURO: Alert and oriented to person, place, time, and situation (x4 HEENT: Normal cephalic CHEST: Breasts tender on palpation, areola darkened and occasional veins present ABDOMEN: Soft; no masses, uterus palpable above umbilicus, mild indenting with palpation, fetus is in LOA position by palpation EXTREMITIES: Mild spider varicose veins on medial aspect of left leg, deep tendon reflexes 2+ PELVIC EXAM: Small amount clear mucous, 7cm/80%/+2, membranes intact What patient assessment findings have clinical significance to the nurse and why? What is the nursing priority at this time? What nursing interventions will the nurse initiate based on the priority at this time? SCIENCE HEALTH SCIENCE NURSING NURSING N325

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