Maternal Newborn Scenarios Stephanie Gold

Stephanie GoldRoom303 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. 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 Increased acuity Increased acuity Normal acuity Explanat Status Assessment reports r/t change in condition Status Assessment reports r/t physiological shifts of pregnancy/cent Status Assessment reports r/t malaise/nausea/pain during pregnanc Status Assessment reports r/t right upper quadrant pain Status Assessment reports r/t concern about her baby’s health/her Status Assessment reports no indication in report that there is a cha 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. You correctly diagnosed8out of10options: Physiological Description Deficient Fluid Volume Imbalanced Nutrition Injury, risk for fetal Injury, risk for maternal Nausea Safety Your Response Explanation False Status assessment reports no generalized edema from fluid assessment/nausea not significant enough to cause deficit. False Status assessment reports assessments do not show nutritio nausea. True Status assessment reports r/t risk for uteroplacental insufÏc pain and malaise/elevated BP indicate preeclampsia/HELLP True Status assessment reports r/t hypertension and vasospasm True Description Fall Risk Status assessment reports experiencing slight nausea off an Your Response True Injury, risk for True maternal Love and Belonging Explana Status assessment reports r/t shifting center of grav trimester. Status assessment reports r/t risk for worsening pre Your Description Response Explana Anxiety True Status assessment reports r/t unknown impact of cur Disabled Family Coping False Status assessment reports no evidence of inappropri for r/t High Risk Pregnancy and Financial Concerns. Health Maintenance; True Status assessment reports r/t deficient knowledge ab Ineffective Stephanie GoldScenario1 The nurse completes an initial assessment. T 37.4 C, 99.3 F; Heart rate 90, regular; RR 20, regular; BP 142/90 mmHg; FHR 145, moderate variability, 2 accelerations to 160 in 20 minutes, no decelerations. No contractions on electronic fetal monitoring or by palpation. Abdomen soft but tender in right upper quadrant. Urine negative for protein on dipstick. No vaginal bleeding or leaking of fluid. No pedal edema. DTR +3 bilaterally. Repeat blood pressure noted to be 144/90 mmHg. The HCP is notified of the assessment and orders are received. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered1out of5actions: Your Correc orde t r order Step 2 1 Explain all plan of care to client and significant other. 4 2 Bedrest/side- Explanation Explanation of plan of care helps put client and significant other at ease, decrease anxiety. The must be done first. Left lateral recumbent position Your Correc orde t r order 3 3 5 4 1 5 Step lying position. Explanation decreases pressure on vena cava, therefore increasing venous return and placental and renal perfusion. This ensures that the fetus is also well perfused and is a priority. CBC, Chemistry Contact the lab to come and Panel, LFT, 24- draw these labs. The results of hour urine for the lab will take several minutes protein and and will drive the plan of care for creatinine. the client. Continuous Client and healthcare team are EFM. concerned about fetus. Hearing fetal heart will decrease client’s anxiety prior to taking her VS. Verifies fetal wellbeing. EFM has been in place but ultrasound and tocotransducer may need to be adjusted after turning client onto her left side. Hourly VS and Client’s BP was elevated and DTR. DTR were brisker than average. By the time other actions have been taken, it will be close to time for the hourly assessments. Stephanie GoldScenario2 The nurse is admitting this client to the high-risk antepartum unit to monitor blood pressure and other assessments and to await lab findings. The nurse adds independent nursing actions to the plan of care. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered0out of6actions: Your Corre orde ct r order Step 6 1 Elevate and pad side rails. 3 2 5 3 Explanation Her DTRs are +3 so she is slightly hyper-reflexic and at risk for seizures. Padding side rails protects her from injury if she has a seizure. Safety first! Ensure oxygen Airway and breathing and suction are precautions next. If client has working properly. a seizure, suction may be needed to clear airway. (She is already positioned on her side) During a seizure, client would have a period of apnea which would cause fetal hypoxemia. Applying oxygen to mother would increase oxygen available to fetus. Ensure both are working before needed in an emergency situation. Emergency Magnesium sulfate, calcium medications gluconate, hydralazine, brought to the nifedipine are often in an client’s room or emergency “toolbox” and verified as brought to client’s room for accessible. immediate access if needed; anticipating one or more of Your Corre orde ct r order 1 4 4 5 2 6 Step Explanation these meds will be ordered if complications such as preeclampsia, eclampsia, or HELLP syndrome occur. This is done as per agency policy. Bring extra pillows Enhancing comfort in the sideto enhance lying position will enable the comfort in sideclient to maintain this position. lying position and Side-lying decreases pressure place between on the vena cava, increases knees, behind venous return, placental and back, and under renal perfusion. Comfort abdomen. measures are completed after emergency interventions. Bring bedpan, Healthcare provider ordered graduated 24-hour urine so bringing cylinder, 24-hour supplies for this collection urine container, would be necessary. The nurse ice into the room. may include intake and output in the care plan independently. At least 30 mL of hourly urine output demonstrates minimal kidney function. Left lateral position enhances renal perfusion, thereby decreasing angiotensin levels, and promotes diuresis. 24 hour I&O documents positive or negative fluid balance. Educate client and Educating and involving the significant others client and significant others in about 24-hour the plan of care helps to urine collection, decrease anxiety and I&O and empower them as important documenting oral members of the health care intake. team. Education occurs after other physiological needs are met. Stephanie GoldScenario3 The nurse reports these abnormal lab reports to the healthcare provider and receives orders to begin magnesium sulfate protocol (4 grams loading dose followed by 2 grams infusion) for HELLP syndrome and betamethasone 12 mg IM q24h x2. The nurse washes hands and applies gloves, verifies the medications and client with 2 identifiers. 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 3 1 Educate the client and her significant other about the medication. 4 2 2 3 Explanation Actively involving client in their own care is a safety strategy, decreases anxiety, and gives the opportunity for verbal consent of the treatment. Initiate peripheral Magnesium sulfate is a high IV with Lactated alert medication and should ringer’s infusing at be administered as a 50 mL/hour. secondary medication. A primary line is started with an isotonic solution, like Lactated Ringer’s. To reduce the risk of pulmonary edema, total intake should be less than 125 mL/hour. Piggyback An initial loading dose of 4 to magnesium sulfate 6 grams over 15-30 minutes Your Corre orde ct r order 5 4 1 5 Step solution into primary IV, set infusion at 400 mL/hour for 15 minutes; volume to be infused 100 mL. IM betamethasone 12 mg. Explanation helps raise magnesium blood levels to a therapeutic level of 4-7 mEq/L and prevent eclamptic seizures. While the loading dose of magnesium sulfate is infusing, administer the IM steroid injection to enhance fetal lung maturity for gestations less than 34 weeks. Neonatal benefit is maximized when the interval between the first injection and birth is longer than 48 hours, but benefits begin within 4 hours of administration. The benefit of one injection is unclear but is often given without harm. Change infusion Followed by an hourly rate to 50 mL/hour infusion of 2grams/hour. An Magnesium sulfate infusion pump is used for 20 grams/500 mL accuracy and less risk of for the remainder of magnesium toxicity. 400 mL. Stephanie GoldScenario4 Two hours into the magnesium infusion, the client states she has a “really bad” headache and she “can’t see very well”. Her eyes become fixed and her facial muscles begin to twitch. The nurse is monitoring fetal heart tones. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: Not all actions will be used. You correctly ordered0out of6actions: Your Correc orde t r order Step Explanation 4 1 Turn head to Keep airway patent and provide one side and for safety from head injury. Side ensure pillow rails are up and padded. under back and shoulder is snug. 6 2 Call for The nurse should call for help assistance but but do not leave the bedside. do not leave Informing the family helps lower client. Keep anxiety. Eclamptic seizures are family informed frightening to watch. of situation. 5 3 Administer During the clonic phase of the oxygen via non- seizure, the client will become rebreather apneic and may result in mask at 10 hypoxemia to the fetus. L/min. Respirations begin with long, deep inhalation. Having the 100% O2 in place will provide for additional oxygen to both mother and fetus. 3 4 Administer Since eclampsia occurred after ordered 4 initiating magnesium sulfate, grams loading additional magnesium sulfate dose of should be given. It is the drug of Your Correc orde t r order 1 5 2 6 Step Explanation magnesium choice for treating eclamptic sulfate IV in 15 seizures and preventing minutes. repeated seizures. Observe and Each stage of the convulsion document should be timed and convulsion documented descriptively. activity. Administer IV Magnesium sulfate is the drug of lorazepam 2 mg choice over other antiseizure over 3-5 medications because it does not minutes. depress the gag reflex. Lorazepam or diazepam are only given if the client is receiving therapeutic levels of magnesium and experiences repeated eclamptic seizures. Stephanie GoldScenario5 The tonic phase lasts 20 seconds and the clonic phase 30 seconds. The client is unresponsive for 1 minute after the seizure with long, deep respirations. No injury is apparent. The client awakes confused and combative. She is coughing large amounts of mucus and states, “What happened? My belly hurts!”. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered3out of5actions: Your Corre orde ct r order Step Explanation 2 1 Asess vital signs Assess post-seizure status of and FHR pattern both client and fetus. Fetal post seizure. distress may occur from hypoxemia during the seizure. Monitor VS frequently until stable. 1 2 Continue oxygen Next, administer oxygen to at 10 L/min per support oxygenation of the mask. client and her fetus and resolve hypoxia. 3 3 Assess uterine During the seizure the uterus activity and may become hypercontractile abdominal and hypertonic. Membranes focused may rupture, cervix may dilate assessment. rapidly. The placenta may separate resulting in abruptio placenta. A rigid broad-like abdomen, pain, and tenderness could be signs of this condition. 4 4 Assess for The client may be incontinent incontinence, during the convulsion. Provide provide hygiene, peri-care and insert and insert indwelling indwelling catheter with urinary catheter. urinometer, for hourly output. Urinary output decreases when there is a reduction of glomerular filtration rate. Report output of < 30 mL/hour. 5 5 Prepare to assist The cervix may dilate rapidly with the birth during a convulsion as the process/instruct uterus is hypercontractile and client and hypertonic. Eclampsia alone is significant other. not an indication for an immediate cesarean deliveryRoute of birth is determined by labor progression, maternal and fetal condition, and gestational age. If abruptio placenta is confirmed with ultrasound and cervix is not dilated, cesarean birth would occur.