Maternal Newborn Scenarios Kesha Jackson

Kesha JacksonRoom302 Kesha Jackson,Patient is a G1P0, gestational age of 33.1. She came in complaining of contractions for 2 hours that are now every 5 mins. She is unsure about rupture of membranes, denying vaginal bleeding and recent intercourse. She states the baby is active. She rates her pain an 8/10. Her current vital signs are 98.1 F, 36.7 C, 92 BPM, 16 breaths/min, 122/64 mmHg, 99% on room air. The fetal heart rate is 135 baseline but is not yet reactive. Cervical exam reveals that she is not dilated or effaced, and the baby’s head is not engaged in the pelvis. She has no medical history and NKA. In obtaining her history, it was learned that she is 15 years old, currently homeless, and has been staying with various friends. She does have some supplies including diapers, wipes, and some clothing that she received from a friend. She expresses the desire to take her baby home with her. She is receptive to teaching and assistance she just has been unsure of how to obtain it. She came to the OB triage via a bus. You responded correctly to6out of6evaluations: Category Educational Needs Fall Risk Health Change Pain Level Psychological Needs Sensorium Your response Explanation Increased Status Assessment reports Kesha will need a lot of education regarding preterm acuity her baby once it arrives Increased Status Assessment reports Client is at increased of fall due to changing center o acuity Increased Status Assessment reports in addition to the pregnancy, there are now addition acuity Increased Status Assessment reports she rates her pain an 8/10 acuity Increased Status Assessment reports Kesha is homeless, is pregnant, is a teen with develo acuity support system. Normal acuity Status Assessment reports no issues reported here. Category Your response Explanation Kesha Jackson Patient is a G1P0, gestational age of 33.1. She came in complaining of contractions for 2 hours that are now every 5 mins. She is unsure about rupture of membranes, denying vaginal bleeding and recent intercourse. She states the baby is active. She rates her pain an 8/10. Her current vital signs are 98.1 F, 36.7 C, 92 BPM, 16 breaths/min, 122/64 mmHg, 99% on room air. The fetal heart rate is 135 baseline but is not yet reactive. Cervical exam reveals that she is not dilated or effaced, and the baby’s head is not engaged in the pelvis. She has no medical history and NKA. In obtaining her history, it was learned that she is 15 years old, currently homeless, and has been staying with various friends. She does have some supplies including diapers, wipes, and some clothing that she received from a friend. She expresses the desire to take her baby home with her. She is receptive to teaching and assistance she just has been unsure of how to obtain it. She came to the OB triage via a bus. You correctly diagnosed11out of13options: Saftey Description Fall Risk Ineffective health maintenance Your Response Explan True Status assessment reports Client is pregnant with increasing risk for falls. True Status assessment reports Client has limited reso healthcare. Description Infection Knowledge Deficit Your Response Explan False Status assessment reports no signs of infection n True Status assessment reports Client does require tea labor plan of care. Psychological Description Anxiety Impaired home maintenance Noncompliance Risk for impaired parenting Physiological Description Acute Pain Decreased cardiac output Impared Mobility Nausea Risk for nutritional imbalance Your Response Explana False No indication True Status assessment reports Client is currently home False True Status assessment reports she has been complaint necessary steps to get help. Status assessment reports Kesha has limited resou support system. Your Response Explanat True Status assessment rates pain 8/10 False Status assessment reports status does not reflect issue False False True Status assessment reports No mobility issues have bee Status assessment reports No reports of nausea. Status assessment reports adolescents who are pregna due to supporting their growth as well as fetal growth. Kesha JacksonScenario1 Kesha is currently on the fetal monitor undergoing a non-stress test. FHR is 130 baseline, moderate variability, no decelerations, but is not having accelerations, with some interruptions in the tracing. 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 Assure that the monitor is tracing fetal heart rate consistently. 2 2 Adjust fetal heart rate monitor. 4 3 Give mother some cold juice to drink. 3 4 Reposition mother to left lateral position. 5 5 Request ultrasound for biophysical profile. Expl It is important to make sure that you are tra is consistent. There could be accels that are interrupted tracing. Adjusting FHR monitor can allow for clearer t might aid in obtaining accelerations. Cold, sugary drinks will often increase fetal h already established a good tracing. Repositioning mother results in fetal repositi However, it often makes tracing more difÏcu and more efÏcient interventions. A biophysical profile can assess overall fetal difÏcult to maintain/other interventions to ob and expensive so should not be used before Kesha JacksonScenario2 The nurse is considering the potential care of Kesha if it is determined that she is in preterm labor. 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 Assess FHR and contraction pattern per monitor. 2 2 5 3 4 4 3 5 Perform sterile cervical exam to determine dilation, effacement, and station. Obtain urinalysis and lab work such as CBC. Administer IV fluids and/or antibiotics. Consider administration of tocolytics. E The presence of contractions is an ind the frequency and intensity of contrac status to assess fetus. A sterile cervical exam will reveal how cervical change is present, magnesium should be considered. Obtaining Urinalysis and lab work can as dehydration or infection. This will g Administering fluids and/or antibiotics lab work have been completed and ha Tocolytics should be considered if othe potential side effects from tocolytics th less effective if the cause is infection o Kesha JacksonScenario3 After a speculum exam to confirm Kesha has not prematurely spontaneously ruptured membranes, a fetal fibronectin is sent and comes back negative. A group beta strep (GBS) culture is sent. Kesha’s contractions have now stopped after treatment with tocolytics. Cervical exam reveals that she is 0.5 cm dilated/ 25% effaced/baby is a -3 station. A bedside ultrasound shows that the baby is in vertex position. Cervical length ultrasound shows that the cervix is 2.0 cm. It has been determined that she is at significant risk for preterm labor to occur again and it has been recommended to give her steroids for fetal lung development. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered5out of5actions: Your Correct order order Step 1 1 Educate Kesha about steroids and the need to Patients should alway administer them. Verify that she understands the medication. They sho rationale to receive the medication using the teach side effects and reaso back method. and consent prior to a 2 2 Verify the 5 rights of medication administration. The 5 rights should al 3 3 Prepare steroids as ordered by the healthcare The medications shou provider. rights have been com 4 4 Choose large muscle for injection and offer ice to Steroid injections sho site. should be offered. 5 5 Establish a plan with Kesha to receive the second Steroids should be giv required dose of steroids in 24 hours. If discharged, establish a means for she may have trouble getting transportation and previous steps. need assistance. Kesha JacksonScenario4 Upon entering Kesha’s room, you notice that she seems upset. When questioned, she expresses concern about finding a place to stay and her ability to care for herself and the baby. 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 Use therapeutic communication. 3 2 Allow her to express her feelings and concerns. 2 3 Ask open ended questions to further develop the conversation. 4 4 Answer any questions openly and offer support. 5 5 Document the conversation. Therapeutic communication should It is important to allow her to expre After the initial communication by t further by asking open ended quest Answering questions and providing a teachable moment. Offer support Documentation should be done last Kesha JacksonScenario5 Kesha is preparing for likely discharge. Kesha requires teaching on the warning signs of preterm labor, the importance of the second dose of steroids, and follow up with healthcare provider. She also needs additional education regarding her options, referrals, resources for assistance, childcare, etc. 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 Use therapeutic communication Therapeutic communication shou techniques. 2 2 Assess her cognitive level and readiness It is important to assess the read to learn. beginning teaching so that the in manner and at the appropriate ti 3 3 Discuss referral to social work/case Information should be provided in management. Provide clear information Written materials should be prov along with printed material that she can later and to reiterate the teachin take with her. include transportation, equipmen 5 4 Allow her to ask any questions that she Questions should be allowed and may have after teaching is complete. so the patient can clarify anythin 4 5 Evaluate her understanding of the After any teaching is completed, information provided using proven understanding of the information techniques such as teach-back or return demonstration.