University:
Helene Fuld College of Nursing
Course:
NUR223 | OB/Pediatric
Academic year:

2023
Views:

93

Pages:

1
Author:

supplicant

Maternity Case 3: Amelia Sung Documentation Assignments 1. Document the fetal status and the progression of Ms. Sung’s labor from the time you took over care of Ms. Sung until the provider takes her to the delivery room.  Patient Amelia Sung is a 36y/o Filipino female, G:2, P:1, L:1 at 39 weeks of gestation who was admitted 24 hours ago for induction of labor. Patient’s status: Pulse: 94, Blood Pressure:148/85, Respiratory Rate: 21, alert, awake and oriented, SpO2 98%, Temp 37C, EFM early deceleration, FHR 102 baby’s head was crowing. 2. Document the essential events related to the time of birth, including the activities and interventions from the time of crowning to the complete expulsion of the fetus. -Interventions taken were:  Room was prepared for arrival of the baby with bassient and delivery table  Step stool was located in the room in the event suprapubic pressure were required  100% Oxygen given per MD order via nonrebreathing mask  Patient was instructed to start pushing with the contractions  Healthcare team was notified when the head was born  NICU was called for assistance with shoulder dystocia  Patient was assisted into McRobert’s position per MD’s order  Charge nurse was called  Suprapubic pressure applied per MD’s order  Patient was encouraged to push  Shoulders were delivered once suprabupic pressure were applied  Baby was handed over to charge nurse for additional assessments 3. Document the application of suprapubic pressure and the response and outcomes.  Once the MD order to apply suprapubic pressure the shoulders were delivered which resulted in a positive outcome. 4. Document your communications with the neonatal intensive care unit (NICU) about the impending birth.  Baby experienced shoulder dystocia, the NICU was informed because of there is risk for hypoxia, shoulder injury such as broken clavical, and injury to the arm. Because the baby can survive for several minutes after the head is born before the baby experiences irreversible damage, every action from the delivery of the head and the call out of shoulder dystocia must be timed.

Documentation Maternity Case 3 Review Notes

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