EHR Cоntinued: NURSING ASSESSMENT & NOTES 2/10 1540 Nursing Nоte: Client аrrives fоr scheduled NST. Client is G1P0 аt 37 weeks gestаtion. She is a single mom. She conceived through intrauterine insemination with donor sperm. EFM and toco applied. FHR: 132. Client states she has had a “nagging” headache since this morning and has been “struggling” with heartburn since yesterday. Blood pressure 162/100 mm Hg. Repeat blood pressure 164/100 mm Hg. Urine dipped for protein, 3+. 2/10 1540 Neuro/Cognitive: A/Ox3. Speech even and clear. Pupils 3 mm PERRLA. Denies any visual changes or disturbances. DTRs 3+, negative clonus. Respiratory: Lung sounds clear bilaterally, breathing unlabored. Cardiovascular: Apical pulse 77, regular, S1 & S2 sounds present. Peripheral Vascular: Skin pink, warm, and dry. +2 pitting edema in left and right lower extremities. Gastrointestinal: Abdomen distended consistent with pregnancy. States she had a bowel movement today. Bowel sounds x 4 quadrants. Last bowel movement yesterday. Genitourinary: Voided 150 mL dark, clear yellow urine. +Proteinuria. Pain: Headache started in morning rates 3/10, describes as nagging. Heartburn rated 3/10, describes as burning, gnawing sensation. 2/10 1630 Nursing Note: Sterile vaginal exam completed. Client is 3 cm dilated, 50% effaced, -2 station. Cervical consistency is medium. Cervix is at misposition. VITAL SIGN TREND Date Temp HR RR BP SpO2 O2 2/10 1535 98.1 °F(36.7 °C) 78 16 162/100 100% RA 2/10 1550 98.1 °F(36.7 °C) 84 18 168/100 100% RA 2/10 1600 deferred 78 18 166/100 99% RA Fetal heart monitor Date FHR Notes 2/10 1535 132 EFM applied 2/10 1555 134 Minimal variability, no decelerations. No contractions noted. Provider 2/10 1600 Prescriptions: Intermittent fetal heart monitoring and contraction monitoring every four hours and continuous once oxytocin started. IV Lactated Ringers 1,000 mL at 125 mL/hour. Initiate Preeclampsia protocols. Labetalol 20 mg IV If severe hypertension persists at 10 minutes, administer 40 mg IV. If severe hypertension persists at 20 minutes, administer 80 mg IV. If severe hypertension persists at 30 minutes, administer another 80 mg IV. If severe hypertension persists at 40 minutes, administer another 80 mg IV. Maximum cumulative dose 300 mg/24 hours: hold if heart rate
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