Notes

0800
A 38-year-old at 39 week’s gestation, G3 T2 P0 A0 L2 came with
complaints of lower abdominal pains radiating to the back with an interval of 3
– 5 minutes. Reports of no leakage, no bloody discharge, and perceives fetal
movements. On assessment, the nurse finds the abdomen soft and not
tender, fetal heart rate of 128 beats/min, and moderate variability noted. Has
moderate contractions on the external uterine contraction monitor. The HCP
Notes on cervical dilation at 0600: was 6cm, the fetal head is not well applied
on the cervix, and was sent to do an ultrasound to confirm amniotic status to
rule out polyhydramnios. The client is alert and oriented x3.