Maternal Newborn Scenarios Clara Guidry

Maternal Newborn Scenarios Clara GuidryRoom302 Clara Guidry,Patient is a 34 y/o G5P4 who gave birth to a 9lb. 3 oz male infant following a 12-hour elective oxytocin 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. You responded correctly to6out of6evaluations: Category Educational Needs Fall Risk Health Change Pain Level Psychological Needs Sensorium Your response Increased acuity Increased acuity Increased acuity Normal acuity Increased acuity Increased acuity Explanation Status assessment reports uterine atony and bleeding and need for fundal massa Status assessment reports patient is still numb from epidural and unable to mov Status assessment reports pooling of blood with large clots. Status assessment does not indicate report of pain and patient is still under effec Status assessment reports pooling of blood, patient reports feeling light-headed, patient unable to sense need to void. Status assessment reports patient reporting feeling light-headed and still numb f Clara Guidry Patient is a 34 y/o G5P4 who gave birth to a 9lb. 3 oz male infant following a 12-hour elective oxytocin 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. You correctly diagnosed10out of13options: Physiological Description Acute Pain Bleeding Deficient fluid volume related to uterine atony/postpartum hemorrhage Impaired mobility Impaired patterns of elimination Ineffective tissue perfusion related to hypovolemia Infection Your Response Ex False Status assessment reports lingering num True Status assessment reports blood pooling secondary to uterine atony because of m use and large infant. True Status assessment reports blood pooling True True True False Status assessment reports effects contin Status assessment reports continued num having been removed previously; patient contribute to uterine atony and hemorrha Status assessment reports blood pooling and light-headed and appears pale Status assessment reports no indication Description Nausea Safety Description Deficient knowledge Your Response Ex False Status assessment reports no indication Your Response Explanat True Status assessment reports patient reports feeling wet from epidural; unaware of potential for uterine atony require education and support. True Status assessment reports patient is still numb from e Disturbed sensory perception Fall, risk for self and risk True for dropping baby Impaired maternal False newborn bonding Peripheral False Neurovascular Dysfunction Status assessment reports lingering numbness from e feeling light-headed Status Assessment reports mother is currently holdin Status assessment reports no indication of increased Clara GuidryScenario1 You enter the patient’s room. After washing and gloving hands, you introduce yourself and verify identities of the patient, Mrs. Clara Guidry and the baby. Assessment findings: Blood pooling under buttocks with several large clots; fundus boggy and slightly deviated to the right, 3 cm. above umbilicus; Vital signs: BP 90/60, P 110, R. 20, SAO2 98%, skin color pale, patient alert and oriented; unable to move legs, holding and breastfeeding baby. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered1out of5actions: Your Correct order order Step 1 1 Assist mother to unlatch infant from Patient is light-headed and hy breast and place infant in crib or hand to mother’s arms. Infant safety the husband. 3 2 Massage uterine fundus. Massaging the fundus until fir vessels at the placental site a 2 3 Call for help using emergency call system. Postpartum hemorrhage is th requiring a rapid, team appro 5 4 Set oxytocin rate to Bolus on IV pump as Rapid infusion of oxytocin cau ordered by healthcare provider. clamping off blood vessels fro 4 5 Assess bladder status and need to A full bladder displaces the ut perform straight catheter. atony. Her uterus is slightly d for catheterization. Clara GuidryScenario2 Assessment reveals a very distended bladder, displacing fundus 3 cm above the umbilicus and displaced to the patient’s right patient unable to void due to lingering effects of epidural. A physician order is received to insert an indwelling urinary catheter. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered0out of5actions: Your Corre orde ct r order Step 4 1 Educate patient regarding indwelling urinary catheter placement, Wash hands. Explanation Education allows for planning and implementation of patient care; washing hands prior to indwelling urinary catheter placement prevents nosocomial infection during invasive procedure and is the Your Corre orde ct r order 5 2 2 3 3 4 1 5 Step Explanation first step. Insert indwelling Insertion of Indwelling urinary urinary catheter catheter is done according to and connect to established protocols, under collection bag, sterile technique and is the secure to patient’s second step. The patient is thigh. unable to void, and a full bladder is a common cause of uterine atony and early postpartum hemorrhage. Measure urine Assesses adequate emptying return in collection of bladder; emptying bladder bag; Reassess returns uterus to normal and uterine tone, position and facilitates normal response to contraction of the uterus. massage, level in relation to umbilicus, and position in abdomen. Reassess vaginal A firmly contracted uterus bleeding and clamps off blood vessels at presence for clots; the placental site, preventing change underpads uterine atony and excessive as needed. bleeding, changing underpads for patient comfort and prevention of infection. Wash hands, Prevents spread of infection; document findings accurate documentation is to and completion of be performed after patient procedure. care is performed, NEVER BEFORE! Clara GuidryScenario3 Following indwelling urinary catheter placement, and upon reassessment, bladder is non-distended, fundus is 1 cm. below the umbilicus, beginning to firm up with massage, but bleeding remains excessive with large clots continuing. Patient remains pale and is anxious. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered1out of5actions: Your Correct order order 5 1 Reassess vital signs. 2 2 1 3 3 4 4 5 Step Indicates physiolog uterotonic meds, B administration. Set plain Lactated Ringers to Bolus rate on IV pump. Next the nurse mu hypovolemia and f Administer Methergine 0.2 mg IM per healthcare Methergine causes provider order. clamping off blood excessive bleeding Assist healthcare provider with exam to assess for Unrecognized cerv cervical or vaginal lacerations/hematoma or retained stage labor and lar placental pieces. bleeding, especiall Anticipate laboratory studies: CBC, blood typing and Laboratory studies crossmatch, coagulation studies. which can cause h Clara GuidryScenario4 Further assessment: no cervical or vaginal lacerations; coagulation studies are WNL, BP 84/56, P 114, R 24, SAO2 94%, fundus firms with massage but otherwise boggy, excessive bright red vaginal bleeding with large clots. Patient complains of feeling more light-headed and is paler. Other registered nurses are caring for the newborn and providing education and support to the husband. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered3out of5actions: Your Correct order order Step 1 1 Administer Oxygen via nonrebreather face mask Hypovolemia from blood at 10-12L/min. circulating oxygen level priority. 2 2 Assist healthcare provider with administration of Causes a sustained firm Your Correct order order 5 3 4 4 3 5 Step misoprostol (Cytotec) 1000 mcg rectally. Establish an additional IV line and anticipate additional crystalloids (Lactated Ringer’s), colloids (albumin), blood and blood products. Continue to closely monitor vital signs, uterine fundus tone/level and vaginal bleeding. Anticipate healthcare provider insertion of postpartum balloon and/or return to operating room. vessels at the placental medication may be give line. Fluid resuscitation and b volume and successful m hemorrhage. Indicates physiologic res uterotonic meds and po components. Balloon exerts inward to resulting in a reduction the endometrium and m Clara GuidryScenario5 Further assessment: BP 106/64, P. 86, R 22, SAO2 97%, fundus firm, 2 cm below umbilicus, lochia moderate, no clots, patient is alert and oriented, less pale, but too tired to breastfeed baby. She expresses a concern about baby not being held or fed. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered0out of5actions: Your Correct order order Step 4 1 Use therapeutic communication/active listening to assess patient’s concerns and interest in pumping for colostrum. 5 2 2 3 3 4 1 5 Active conce done Consult Lactation Consultant or provide education to patient and Provid assist with pumping. Discuss with patient’s partner for willingness/interest to feed Allow baby colostrum. pater Assist partner in feeding pumped colostrum and partner skin-to- Promo skin contact. Assess patient’s ability to hold infant and assist patient with Facilit holding baby skin-to-skin after feeding for maternal-infant mater bonding.