The nurse is interviewing the mother of an infant. She reports, "I had a difficult delivery, and my baby was born prematurely." This information should be recorded under which heading?

The correct answer is choice D. Birth history.

Choice A rationale:

The heading "Chief complaint" is used to document the primary reason for the patient seeking medical attention, such as their main symptom or concern. This is usually stated in the patient's own words and provides context for the visit, but it does not encompass information about the circumstances of birth or prematurity.

Choice B rationale:

"Review of systems" involves a systematic approach to inquire about the patient's current symptoms or physical complaints across different body systems. It helps to identify any additional issues the patient might not have mentioned initially, but it does not pertain to birth history or prematurity.

Choice C rationale:

"Present illness" is the section where the nurse documents the patient's current health concern, including the details of the symptoms, their onset, duration, and any associated factors. However, it does not encompass information about the circumstances of birth or prematurity.

Choice D rationale:

"Birth history" is the most appropriate heading for recording information about the infant's delivery, including any difficulties during delivery and the fact that the baby was born prematurely. This information is relevant for understanding the infant's medical background and potential risk factors associated with prematurity.