A woman presents to the clinic in the first trimester of pregnancy.

She has three children living at home.

One of them was born prematurely at 34 weeks.

The other two were full-term at birth.

She has a history of one miscarriage.

How do you record her obstetric history on the chart using GTPAL format?

Choice A rationale

Immediately initiating urological testing without first assessing for psychological factors is premature. While organic causes of enuresis exist, a sudden onset in a 12-year-old following a significant stressor like parental divorce strongly suggests a psychological etiology. Unnecessary invasive testing can be distressing for the child.

Choice B rationale

Punishing a child for bedwetting is detrimental and ineffective. Enuresis, especially stress-induced, is an involuntary act; punishment increases anxiety and shame, exacerbating the problem rather than resolving it. This approach can damage the child's self-esteem and the parent-child relationship.

Choice C rationale

Informing the child they are too old for bedwetting shames them and ignores the underlying emotional distress. This approach fosters guilt and inadequacy, reinforcing negative self-perceptions rather than addressing the root cause. Empathy and support are crucial for managing stress-related symptoms.

Choice D rationale

Providing emotional support and assessing for enuresis as a stress response is the most appropriate initial intervention. The sudden onset of bedwetting after parental divorce strongly suggests a psychological component. Addressing the emotional impact and providing coping strategies can alleviate the stress, leading to resolution of the enuresis.

The nurse should determine that the FHR pattern represents Early decelerations due to Fetal head compression during contractions.

Rationale for correct answers:

Early decelerations are a gradual decrease and return to baseline of the fetal heart rate (FHR) associated with uterine contractions. They mirror contractions, beginning and ending with the contraction. This pattern is physiologic and typically benign.

Fetal head compression during contractions causes a vagal response leading to early decelerations. At a station of +4 and full dilation, fetal descent is significant, making head compression the most likely cause.

Rationale for incorrect Response 1 Options:

Late decelerations occur after the peak of the contraction and are due to uteroplacental insufficiency. These are non-reassuring and do not mirror contractions, unlike what is noted in the case.

Variable decelerations are abrupt drops in FHR and vary in timing, shape, and duration. They are not mirror images and are often associated with cord compression, which is not supported by this case’s findings.

Prolonged decelerations last >2 minutes and <10 minutes. The decelerations in this case are transient (to 105 bpm) and resolve before the end of the contractions, ruling out prolonged patterns.

Rationale for incorrect Response 2 Options:

Umbilical cord compression leads to variable decelerations, which are abrupt and not aligned with contraction timing, unlike the current pattern.

Uteroplacental insufficiency results in late decelerations, which occur after the contraction ends. These are non-reassuring and not consistent with the current findings.

Maternal hypotension due to epidural could cause late decelerations from reduced placental perfusion. However, despite a BP drop at 0900 (100/52 mm Hg), the FHR deceleration pattern does not match.

Take home points:

• Early decelerations are benign and typically reflect fetal head compression during contractions.
• Differentiate early from late decelerations based on timing relative to contractions—early mirrors, late lags.
• Variable decelerations are abrupt and typically linked to umbilical cord compression, not head compression.
• Maternal hypotension from epidural requires close monitoring, but it leads to uteroplacental insufficiency and late decelerations, not early.