Sydney Small
1. Review the Case study.
2. Identify the Presumptive, probable, and positive signs of pregnancy
Presumptive Signs
Probable Signs
Positive signs
Nausea & vomiting
Fatigue
Breast tenderness
Unknown LMP
3. Create an SBAR report.
Situation should include
Gravida/Para or GTPAL and Report
of LMP, with estimation of EDC.
Background should include
pertinent data from reproductive
history, medical history, and family
history as well as lifestyle
information
Assessment should include
objective and subjective data points
that are important to the current
situation. Signs of pregnancy will go
here as well as your estimation of
gestational age.
Recommendations: What follow-up,
education is needed based on
assessment and gestational age?
What diagnostic tests should be
run?
Should lifestyle changes be made?
Should medications be changed?
Are vaccinations needed at this
time?
Interdisciplinary: should referrals
occur?
Should other healthcare services be
engaged during this or subsequent
visits?
Positive HCG (15 IU/mL)
Fundal height 26 cm
Hegar’s sign (+)
Chadwick’s sign (+)
Ballottement noted
Linea nigra
FHR auscultated (150)
S: Nulliparous; G1-000. Unknown LMP. Estimated EDC (without
LMP) in 12-16 weeks.
B: 15 yr old sophomore in HS. Menarche at 14, reports irregular
periods. Does not recall LMP. Multiple sexual partners; not in a
serious relationship. Hx of asthma; prescribed Fluticasone &
salmeterol, and Albuterol. Father has Hx of HTN & DM-II. Denies
smoking/drinking. Plays volleyball 5-7 x a week. Eats out 2-3 x a
week; lunches at school. Scared of father; mother not aware of
sexual activity.
A: Patient complains of fatigue, nausea & vomiting, breast
tenderness, rapidly growing waistline & weight gain. HCG of 15
IU/mL, positive Hegar’s and Chadwick’s signs, ballottement and
linea nigra noted. Fundal height 26 cm. FHR auscultated at 150
bpm. Estimated gestational age (based on fundal height) 26
weeks.
R: Education on pregnancy anatomy/physiology & child
development in 2nd trimester, comfort measures, danger signs, &
optional genetic testing opportunities. Ultrasound needed to more
accurately determine gestational age & EDC. Blood typing, quad
screen, and glucose testing recommended. Cessation of volleyball
during duration of pregnancy should be advised. Assessment of 24
hour diet recall; nutritional recommendations, including
supplements, caloric increase, foods to avoid, and food safety.
Switching to a safer alternative to Advair may be beneficial.
Influenza & Tdap recommended; Hepatitis A & B, meningococcal,
& pneumococcal recommended if indicated. Referrals to an
obstetrician, dietitian, & possibly a counselor/psychologist to
evaluate family/caregiver dynamics & feelings about pregnancy.
Scheduling of further prenatal visits should be discussed.