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Maternal newborn - notes
Medical surgical (257)
East Coast Polytechnic Institute
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Stephanie Gold, 19-year-old Caucasian female, G1 T0 P0 A0 L0, 32 weeks gestation. Uncomplicated pregnancy except for anemia treated with PO iron. States 3 times in last week has called on-call obstetrician about fatigue, body aches, mild nausea during the evening. The client reports, “I don’t feel well, I haven’t vomited, but nausea makes me not want to eat too much. I am drinking ok, just want to eat bland foods.” Rest and acetaminophen were recommended. Client is first-year nursing student and states several students have had a “GI bug”. States during day felt better and went to school all but one day. No fever. She stated: “Can’t be absent from nursing school!” No contractions, leaking of fluid or vaginal bleeding. Came in this morning (Saturday) due to pain by right rib cage. States this is new today. Boyfriend accompanies client.
Educational- increases acuity Fall risk-increased acuity HEalth change- increased acuity Pain level- increased acuity Psychological needs- increased acuity Sensorium- normal acuity
Clara Guidry, Patient is a 34 y/o G5P4 who gave birth to a 9lb. 3 oz male infant following a 12-hour elective cin induction of labor. She had an uncomplicated labor, epidural anesthesia and a rapid second stage, no episiotomy or perineal lacerations. Indwelling urinary catheter was removed prior to delivery. She is now one hour postpartum and is breastfeeding her baby. An IV of 1000 mL Lactated Ringers is infusing at KVO rate with an infusion of Lactated Ringers with oxytocin 20 Units infusing IVPB at 125 mL/hour. Upon entering her room, she tells you that she “feels wet”, and may have urinated on herself since she is still numb from the epidural and unable to move legs. Your assessment reveals blood pooling under buttocks onto the underpads with numerous large clots. She is anxious, appears pale, and complains of feeling light-headed. Her husband is at her bedside.
Educational- increased acuity Fall risk-increased acuity HEalth change- increased acuity Pain level- normal acuity Psychological needs- increased acuity Sensorium- increased acuity
Physiological: Acute pain, bleeding, deficient fluid volume related to uterine atony, impaired mobility, infection Safety:Fall risk, impaired maternal newborn bonding, peripheral neurovascular dysfunction
Jenny Smith, 23-year-old, G2P1, estimated gestation age of 10 weeks with complaints of vaginal bleeding and abdominal cramping. No medical hx, allergic to sulfa drugs. Lab results showed a decreased serum HCG from previous result. No fetal movement seen by ultrasound and no fetal heart tones could be obtained. Pelvic exam revealed an open cervical os with blood noted. She states that her pain is abdominal cramping, rates it from a 4/10 to a 7/10 and is still having vaginal bleeding. She has pain medication prescribed q4h prn and received a dose about 1 hour ago with some relief. Her vitals are stable at 98 F., Heart rate 89 bpm, 18 breaths/minute, 132/68 mmHg, O2 Saturation 98% on room air. She’s currently NPO until the need for dilation and curettage is ruled out. She has an IV in her left forearm, no fluids infusing at this time. She verbalized understanding of the findings and is visibly upset. She expresses concern about her family dealing with the loss and how she will tell them. She has been speaking with the staff about loss and is receptive to education regarding the next steps.
Educational- increased acuity Fall risk-increased acuity HEalth change- increased acuity Pain level- increased acuity Psychological needs- increased acuity Sensorium- normal acuity
Jessica Wu, 35-year-old Asian female, G3 T2 P2 A0 L2, 35 weeks gestation. NKDA. Previous pregnancies uncomplicated but Cesarean births due to persistent breech position. Smoker x 15 years but states she “cut back to 3 cigarettes/day during her pregnancies.” Reports that she started smoking during college. States started having moderate amount of bright red bleeding about 0800. Came to the hospital after dropping the older children at school (5 and 7 years old). She has called her husband and he is meeting her at the hospital because he was already at work. It is now 0945. She is anxious about the bleeding. States she “never had anything like this with her other pregnancies!” Denies pain, contractions, or leaking of amniotic fluid.
Educational- increased acuity Fall risk-increased acuity
Upon entering her room, she tells you that she “feels wet”, and may have urinated on herself since she is still numb from the epidural and unable to move legs. Your assessment reveals blood pooling under buttocks onto the underpads with numerous large clots. She is anxious, appears pale, and complains of feeling light-headed. Her husband is at her bedside.
Physiological- acute pain, deficient fluid, impaired mobility,
Jessica Wu 35-year-old Asian female, G3 T2 P2 A0 L2, 35 weeks gestation. NKDA. Previous pregnancies uncomplicated but Cesarean births due to persistent breech position. Smoker x 15 years but states she “cut back to 3 cigarettes/day during her pregnancies.” Reports that she started smoking during college. States started having moderate amount of bright red bleeding about 0800. Came to the hospital after dropping the older children at school (5 and 7 years old). She has called her husband and he is meeting her at the hospital because he was already at work. It is now 0945. She is anxious about the bleeding. States she “never had anything like this with her other pregnancies!” Denies pain, contractions, or leaking of amniotic fluid.
Physiological- Acute pain, deficient fluid volume, injury risk for fetal, fall risk, anxiety, fear
Stephanie Gold 19-year-old Caucasian female, G1 T0 P0 A0 L0, 32 weeks gestation. Uncomplicated pregnancy except for anemia treated with PO iron. States 3 times in last week has called on-call obstetrician about fatigue, body aches, mild nausea during the evening. The client reports, “I don’t feel well, I haven’t vomited, but nausea makes me not want to eat too much. I am drinking ok, just want to eat bland foods.” Rest and acetaminophen were recommended. Client is first-year nursing student and states several students have had a “GI bug”. States during day felt better and went to school all but one day. No fever. She stated: “Can’t be absent from nursing school!” No contractions, leaking of fluid or vaginal bleeding. Came in this morning (Saturday) due to pain by right rib cage. States this is new today. Boyfriend accompanies client.
Imbalance fluid volume, injury risk for fetal, injury risk for maternal, nausea, fall risk, anxiety, disabled family coping
23-year-old, G2P1, estimated gestation age of 10 weeks with complaints of vaginal bleeding and abdominal cramping. No medical hx, allergic to sulfa drugs. Lab results showed a decreased serum HCG from previous result. No fetal movement seen by ultrasound and no fetal heart tones could be obtained. Pelvic exam revealed an open cervical os with blood noted. She states that her pain is abdominal cramping, rates it from a 4/10 to a 7/10 and is still having vaginal bleeding. She has pain medication prescribed q4h prn and received a dose about 1 hour ago with some relief. Her vitals are stable at 98 F., Heart rate 89 bpm, 18 breaths/minute, 132/68 mmHg, O2 Saturation 98% on room air. She’s currently NPO until the need for dilation and curettage is ruled out. She has an IV in her left forearm, no fluids infusing at this time. She verbalized understanding of the findings and is visibly upset. She expresses concern about her family dealing with the loss and how she will tell them. She has been speaking with the staff about loss and is receptive to education regarding the next steps.
Acute pain, altered family process, bleeding decreased cardiac output, ineffective airway clearance, ineffective coping, suicidal ideations, fall risk, imparied mobility
32 y/o G3P2 at 39 weeks gestation. It has been 10 years since her last pregnancy. She was admitted to Labor & Delivery late last night in active labor. Upon admission, sterile vaginal exam (SVE) was 2 cm dilated, 80% effaced and -1 station (2/80/-1). She had small amount of bloody discharge, but membranes were intact. Contractions were every 3-4 mins., lasting 50-80 secs., with reassuring fetal heart rate (FHR). She rated her pain as 3 on 0-10 pain scale and stated most of the pain was in her back and vaginal area. Ms. Johnson was weighed on admission at 250 pounds, she reported that she is allergic to penicillin, and has mild scoliosis. On admission, Ms. Johnson admitted that she does not tolerate pain well and wants an epidural like she had with her previous pregnancies. Her significant other is in the room on the couch playing games on his IPAD, and frequently texting on his phone. At 0630, her water broke (SROM-spontaneous rupture of membranes) and fluid was clear. SVE is 4 cm dilated, 90% effaced, and 0 station (4/90/0) with contractions every 2-3 mins., lasting 40-70 secs., with reassuring FHR. Pain level is 7-8 out of 10, and she became increasingly irritable, short tempered, and requested an epidural. IV fluids, 1000 ml of Lactated Ringers were infused at 125ml/hr. per order. There are signed orders for an epidural PRN (as needed).
Risk for imparied urinary elimination, risk for maternal injury, deficient knowledge, fall risk for
gauge lactated 5.) Rh immunoglobulin 300 mcg 6.) IM
betamethasone 12 mg
Ultrasound shows a partial posterior placenta previa. Biophysical
profile 10/10 and normal Amniotic fluid volume. Chem Panel normal.
Hgb 10 g/dL and HCT 30%. Platelets 160,000. The nurse admits the
client for expectant management of placenta previa. SELECT THE
FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD
BE IMPLEMENTED: Not all interventions should be completed
1.)Assist client to lateral positioning 2.) maintain Iand O 3.) bring
extra pillows 4.) Bring bed pan 5.) educate client and husband 6.)
prepare to assist with a vaginal exam
The client’s condition stabilized and bleeding stops. After 48
hours, she is discharged to home with the following instructions.
The nurse selects instructions as part of the nursing actions.
SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER
THAT THEY SHOULD BE IMPLEMENTED:
1.)If bleeding resumes return to hospital 2.)keep all
appointments 3.) Ensure the client lives within a short
distance 4.) discuss willingness to comply 5.) discuss
diversionary activities and provide resources
Two weeks later, Jessica returns to the hospital. She is
now 37 weeks gestation. She says, “I woke up in a puddle
of blood this morning. I wasn’t doing anything! I’m not
having any pain or contractions.” Her husband says he
called her doctor and the doctor is meeting them at the
hospital. SELECT THE FIRST TWO NURSING ACTIONS IN
THE ORDER THAT THEY SHOULD BE IMPLEMENTED:
1.)Call for assistance, 2.) obtain vitals 3.) administer
oxygen via non rebreather 4.) insert 18 gauge IV with
normal saline 5.) insert indwelling catheter
Renee Wilson scenario 1
1.)Discuss c-section, allow woman to verbalize feelings,
praise woman and husband for efforts, encourage frequent
positions, suggest changing to a more complex breathing
techniques
Scenario 2
Assist woman to bed, using sterile glove test fluid, asses color, asses
contraction, reassess maternal vital signs
Scenario 3
Reassess maternal and fetal status, encourage her to void, assist with
peri care, teach husband how to apply counter pressure, continue to
provide comfort
Scenario 4
Asses fhr before removing transducer, insert foley cath, apply
sequential compression device, perform lap needle and instrument
count, perform time out
Scenario 5
Assist in drying, perform apgar, asses vital signs, place matching ID
bands, place infant skin to skin
After obtaining report, the nurse looks in the computer for Jennifer’s
prenatal record and lab reports. She is A+, Rubella immune, and GBS
Sensorium- normal acuity
Aminiah Hussain
Physiological- Acute pain, chronic pain, fall risk, injury risk for
fetal, injury risk for maternal,
anxiety, deficient knowledge, disbaled family coping, fear,
spiritual distress
Scenario 1
Wash hands, ask client and husband what they prefer to be
called, ask if there is need for an interpreter, ask for permission,
educate client about the status of fetal
Scenario 2
Who do you want to be in with you in labor, what can your labor
support person do to help you be most comfortable, what
actions are important for you and your fam, what do you expect
from the nurses, how will other members of the family
participate
Scenario 3
1.)Provide written
2.)Female health care providers
3.)After birth
4.)Assess 1min
5.)Allow mother to rub a soft date
Scenario 4
Assess fetal status, asses contraction, initiate primary IV,
Oxytocin 30 units, assess BP
Scenario 5
1.)Discontinue the oxytocin
2.)Reposition the client
3.)Administer oxygen
4.)Administer IV
5.)Administer terbutaline
Jamie
Maria Sanchez Room 304
20 year old female, G1 P1 L1, 39 weeks gestation. Pregnancy uncomplicated Educational: Increased Fall Risk: Increased Health changes: Increased Pain Level: Increased Psychological Needs: Increased Sensorium: Normal **SAFETY ** Fall risk: TRUE Injury, risk for maternal: FALSE **PHYSIOLOGICAL ** Acute Pain: TRUE Chronic Pain: FALSE Ineffective breastfeeding, risk for: TRUE Infection, risk for: TRUE **LOVE AND BELONGING ** Anxiety: FALSE Deficient knowledge: TRUE Readiness for enhanced parenting: TRUE
SCENARIO 1
- Wash hands and introduce self to the client and her husband.
- Ask the client and her husband what they prefer to be called.
SCENARIO 2
- Reassure Maria that engorgement is a common and temporary condition.
- Instruct Maria to breastfeed Juan every 2-3 hrs.
SCENARIO 3
- “Position your baby skin to skin w/ you for a few minutes”.
- “Hold your baby like a football”
SCENARIO 4
SCENARIO 1:
- Use therapeutic communication and express that you are here to listen if she wishes to talk.
- Assess her overall condition and v/s if available.
SCENARIO 2:
- Assess v/s
- Assess amount of current vaginal bleeding.
SCENARIO 3:
- Assess v/s
- Assess vaginal bleeding amount and odor.
SCENARIO 4:
- Explain to Jenny about the plan of care
- Ensure that the consent is obtained prior to the surgery.
SCENARIO 5:
- Assess Jenny’s current v/s
- Assess current bleeding
SCENARIO 6:
- Assess Jenny’s current status/physical readiness for discharge
- Verify blood type
Jennifer Humes Room 301
30 year old Caucasion female, G4 T2 P0 A1 L2, 33 5/7 weeks gestation. Hx of chronic hypertension and gestational hypertension w/ this pregnancy. EDUCATIONAL: Increased FALL RISK: Increased HEALTH CHANGE: Increased PAIN: Increased PHYSIOLOGICAL: Increased SENSORIUM: Normal **PHYSIOLOGICAL ** Acute Pain: TRUE Chronic Pain: FALSE Decreased Cardiac Output: FALSE Deficient fluid volume, risk for: TRUE Ineffective tissue perfusion: FALSE Injury, risk for fetal: TRUE **SAFETY **
Fall risk: TRUE Injury, risk for maternal: TRUE
**LOVE AND BELONGING ** Anxiety: TRUE Disabled: FALSE Fear: FALSE Grieving: TRUE Health maintenance: TRUE
SCENARIO 1
- Wash hands and introduce self to the clent and her husband
- Obtain her v/s, fetal heart tone, and perform a pain assessment
SCENARIO 2
- Maintain bedrest/side lying position
- Obtain CBC, chemistry panel, ultrasound/Biophysical profile
SCENARIO 3
- Maintain bedrest
- Bring extra pillows to enhance comfort in side lying position and place between knees, behind back, and under abdomen
SCENARIO 4
- Teach that if bleeding resumes, return to the hospital immediately.
- Teach the client to keep all appointments for prenatal visits, fetal assessments, and lab tests.
sCENARIO 5
- Call for assistance but do not leave the client. Keep family/partener informed of the situation.
- Obtain her v/s, fetal heart tones, and perform a pain assessment.
Sarah Lane Room 302
25 y/o G2P0 who is at 42 weeks gestation. Estimated fetal weight is 4000 Gm. She presents to the Maternal Fetal Medicine Clinic for a Non stress test (NST). EDUCATIONAL: Increased FALL RISK: Increased HEALTH CHANGE: Increased PAIN: Normal PHYSIOLOGICAL: Increased SENSORIUM: Normal
- If baseline remains nonreactive, activates vibroacoustic stimulation
SCENARIO 5
- Review mother tracing and interpret NST results.
- Consult w/ prescribing healthcare provider regarding assessment findings and NST interpretation.
- Educate
- Schedule woman for followup
- Document performance
Kesha Jackson Education needs- increased acuity Fall risk- increased acuity Health change- increased acuity Pain level- increased acuity Psychological needs- increased acuity Sensorium- normal acuity
Kesha Jackson Ineffective health maintance, infection, knowledge deficit, impaired home maintenance, noncompliance, risk for impaired parenting, acute pain, decreased cardiac output, impaired mobility, nausea, risk for nutritional imbalance
Susie Smith Education needs- increased acuity Fall risk- increased acuity Health change- increased acuity Pain level- normal acuity Psychological needs- increased acuity Sensorium- increased acuity Kesha Jackson Scenario 1 1.) Assure that the monitor is tracing fetal heart rate 2.) Adjust fetal heart rate monitor 3.) Give mother some cold juice to drink 4.) Reposition mother to the left lateral position 5.) Request ultrasound for biophysical profile
Scenario 2
1.) Assess FHR and contraction 2.) Perform sterile cervical 3.) Obtain urinalysis 4.) Administer IV 5.) Consider administration of tocolytics
Scenario 3 1.) Educate Kesha about the steroid 2.) Verify the 5 rights 3.) Prepare steroids 4.) Choose large muscle 5.) Establish a plan with kesha
Scenario 4 1.) Use therapeutic communication 2.) Allow her to express her feelings 3.) Ask open ended question 4.) Answer any questions 5.) Document conversation
Scenario 5 1.) Use therapeutic communication 2.) Asses cognitive level and readiness 3.) Discuss referral to social work 4.) Allow her to any questions that she may have 5.) Evaluate her understanding
Susie Smith Acute pain, anxiety, bleeding, nausea, deficient knowledge, disturbed sensory perception, fall risk, risk for ineffective coping
Scenario 1 1.)Discuss with woman fears 2.)Educate woman on oxytocin 3.) have woman empty bladder 4.) position woman semi fowlers 5.) reassess placement of tocodynamoneter
Scenario 2
Renee Workman Scenario 1 1.) Wash hands 2.) Introduce self explain assessment 3.) Apply electronic fetal monitor 4.) Assess maternal vitals 5.) Ausculate heart and breath sounds 6.) Assess peripheral edema and reflexes
Scenario 2 1.) Turn the client to her left side 2.) Elevate and pad side rails 3.) Apply oxygen at 10L/min 4.) Emergency medications brought to the clients room 5.) Notify healthcare provider of assessments
Scenario 3 1.) Post signs 2.) Ask the client to void and discard the urine 3.) Place the urine in the special container or on ice 4.) Collect all the urine in the next 24 hours 5.) Ask the client to void and save the urine 6.) Label and send the urine specimen to the lab Scenario 4 1.) Renee Workman blood work results reveal HELLP syndrome, Renee is 36 weeks gestation, NST reactive but minimal variability, What magnesium sulfate loading dose and infusion rate, Read back HCP
Scenario 5 1.) In a calm voice 2.) Use therapeutic touch 3.) Provide the client with a cool washcloth 4.) Assess the clients vitals 5.) Ask the wife to leave the room 6.) Notify the healthcare of the adverse effects
Maternal newborn - notes
Course: Medical surgical (257)
University: East Coast Polytechnic Institute
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