General Appearance

Vitals: BP, pulse, respirations, temperature.

HEENT: Funduscopy, facial edema, jugular venous distention.

Chest: Wheezes, rhonchi.

Cardiovascular: Rhythm, S1, S2, murmurs.

Abdomen: Fundal height, Leopold's maneuvers (lie, presentation).

Estimated fetal weight (EFW), tenderness, scars.

Cervix: Dilatation, effacement, station, position, status of membranes, presentation. Vulvar herpes lesions.

Extremities: Cyanosis, clubbing, edema.

Neurologic: Deep tender reflexes, clonus.

Prenatal Labs: Obtain results of one hour post glucola, RPR/VDRL, rubella, blood type, Rh, CBC, Pap, PPD, hepatitis BsAg, UA, C and S. Current Labs: Hemoglobin, hematocrit, glucose, UA; urine dipstick for protein.

Assessment: Intrauterine pregnancy (IUP) at 40 weeks, admitted with the following problems:

Plan: Anticipated type of labor and delivery. List plan for each problem.

H. Extremities. Severe lower extremity or hand edema suggests preeclampsia. Deep-tendon hyperreflexia and clonus may signal impending seizures.

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