Maternal Newborn Scenarios Carly Madison

Carly MadisonRoom302 Carly Madison,30 y/o G1P0 who was admitted 4 hours ago in labor. Her cervical exam on admit revealed: 4 cm, 70%, fetal vertex at -1, slight bloody show, leaking membranes. She doesn’t remember when the leaking began. Contractions on admit were q 5 minutes x 45 seconds. Mrs. Madison reported a pain level at 4/10. She and her husband have been to a Lamaze Prepared Childbirth series and their Birth Plan includes the desire for a non-medicated labor and birth. She and her husband have been doing Slow-Chest breathing and conscious relaxation techniques since admission. She is NPO other than ice chips; she has no IV at this point. Vital signs – BP 124/70, P 80, R 20, FHR is reassuring with a 136 BPM baseline with moderate variability no decelerations and +accelerations (Category 1). She is ambulating in her room with a portable maternal-fetal monitor applied. She puts her call light on and ask to see a nurse stating, “how much longer is this going to be? I am getting really tired.” You responded correctly to4out of6evaluations: Your response Explanation Increased Status assessment reports she is a G1 having attended childbirth classes, but fir acuity reinforcement of concepts learned. Increased Patient is term gestation in labor and ambulating in the room. Term gestation alt acuity Health change Normal acuity Status assessment indicates normal vital signs and maternal-fetal status. Pain level Increased Status assessment indicates a pain level of 4/10, desiring an unmedicated birth. acuity Physiological Increased Status assessment indicates that the client is in labor. Needs acuity Sensorium Needs Normal acuity Status assessment reports no indication of increased sensorium acuity. Category Educational Needs Fall Risk Carly Madison 30 y/o G1P0 who was admitted 4 hours ago in labor. Her cervical exam on admit revealed: 4 cm, 70%, fetal vertex at -1, slight bloody show, leaking membranes. She doesn’t remember when the leaking began. Contractions on admit were q 5 minutes x 45 seconds. Mrs. Madison reported a pain level at 4/10. She and her husband have been to a Lamaze Prepared Childbirth series and their Birth Plan includes the desire for a non-medicated labor and birth. She and her husband have been doing Slow-Chest breathing and conscious relaxation techniques since admission. She is NPO other than ice chips; she has no IV at this point. Vital signs – BP 124/70, P 80, R 20, FHR is reassuring with a 136 BPM baseline with moderate variability no decelerations and +accelerations (Category 1). She is ambulating in her room with a portable maternal-fetal monitor applied. She puts her call light on and ask to see a nurse stating, “how much longer is this going to be? I am getting really tired.” You correctly diagnosed9out of12options: Physiological Your Response Acute Pain True Status assessment reports p childbirth techniques for pa Anxiety Related to Labor and Birthing Process True Status assessment reports p Fatigue Related to Energy Expenditure Required True Status assessment reports for Labor and Coping Skills hours and ambulating in roo Impaired Comfort True Status assessment reveals relaxation techniques. Impaired urinary elimination False Status assessment reports n Nausea False Status assessment reports n Risk for Fluid Volume Deficit True Status assessment reports p fluids. Safety Description Your Description Response Deficient Knowledge True Disturbed sensory perception False Exp Status assessment reports that despite hav Status assessment reports no disturbance Description Fall, Risk for Risk for fetal injury Risk for Maternal Infection Your Response False False True Exp Status assessment reports no increased fa Status assessment reports as reassuring w Status assessment reports leaking membra Carly MadisonScenario1 You enter the patient’s room. After washing and gloving hands, you identify yourself and the patient, Mrs. Carly Madison. She appears anxious, has switched to shallow-chest breathing and is now sitting in the rocking chair. She says she hasn’t had a cervical exam since she was admitted and is anxious to see if she has progressed any. Her Healthcare Provider arrives to examine her and states he may perform an amniotomy (AROM). 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 3 1 Offer support and explain to the woman what will be done, assisting her to a lithotomy position with slight lateral tilt. 4 2 Assess the FHR before procedure to obtain a baseline reading. 1 3 Place a clean, dry pad under the woman’s buttocks to absorb fluid. 2 4 Assist the healthcare provider who is performing exam by Education patient ca The proce fetal statu Keeps pat promote c Prevents a Your Correct order order 5 5 Step opening sterile gloves, lubricant and sterile amniotomy hook. Reassess the FHR and document assessment; assess and record the color, consistency ad odor of the amniotic fluid. Carly MadisonScenario2 The healthcare provider’s exam reveals the cervix to still be 4 cm. dilated but now 100% effaced, and fetal vertex at a 0 station. There is a moderate amount bloody show; AROM yielded clear fluid. Contractions have not changed in frequency or intensity since admit. The healthcare provider discusses with the patient the potential to begin oxytocin if the amniotomy does not increase the contraction pattern and facilitate cervical change. The healthcare provider and the registered nurse discuss a plan for active labor management with the patient and her husband. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered0out of5actions: Your Correc orde t r order Step 2 1 Reassure client that progress has been made; review plan with the woman and husband and assess understanding. Explanation Reassurance is important. Primigravidas may efface before dilating more and head is descending well. Education allows for planning and Possibility should exh Your Correc orde t r order 4 2 1 3 5 4 3 5 Step Explanation implementation of patient care. Assist woman to A full bladder can impede restroom to empty fetal descent and increase her bladder. woman’s discomfort during contractions. Encourage use of Promotes comfort, birthing ball especially easing back pain and pelvic pressure Reassess fetal heart The fetal heart rate and rate and contraction contraction pattern should pattern every 30 be reassessed every 30 minutes minutes during the latent and active phase of labor Document the The plan of care has been updated plan of care updated and should be in the electronic reflected in the electronic medical record medical record Carly MadisonScenario3 Two hours later, the healthcare provider performs another vaginal exam. Assessment findings: Cervix 5 cm., 100%, 0 station; contractions are q 5 minutes, lasting 60 seconds, but intensity remains unchanged. FHR is evaluated as Category 1. The healthcare provider gives the nurse a verbal order to begin oxytocin (Pitocin) at 1 mu/minute, increasing by 1-2 mu/min every 30 minutes. A standard concentration of 500 mL Lactated Ringer’s with 30 units oxytocin is used. 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 4 1 Reassure client that progress is being make; educate the woman and her husband on the reasons for augmentation and anticipated response to medication. 1 2 2 3 3 4 Assess maternal vital signs and FHR immediately prior to initiating oxytocin and then every 15 minutes. Administer oxytocin intravenously through a secondary line connected to the main line at the proximal port (closest to patient) with an IV pump. Monitor contraction pattern and palpate uterine resting tone Explanation Reactions to expect concerning nature of contractions with oxytocin use prepares woman for coping. Client may be questioning her birth plan and need reassurance of progress. Alterations in maternal vital signs and a nonreassuring FHR can occur with oxytocin. Prevents an inadvertent bolus of oxytocin if discontinued and mainline LR is increased. Abnormal contraction patterns, including uterine tachysystole can Your Correc orde t r order 5 5 Step every 15 minutes and with every dose change. Document initiation of oxytocin and every increase, decrease or discontinuance. Explanation occur. Careful titration of oxytocin is essential for safe maternal and fetal tolerance. Carly MadisonScenario4 Two hours later Mrs. Madison is successfully using her breathing and relaxation techniques and reports her pain level at 5/10. Her husband is providing massage to assist with pain management. She reports increased vaginal pressure and is experiencing a moderate bloody show with clear amniotic fluid. Sterile vaginal exam (SVE) reveals no cervical change. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered5out of5actions: Your Correc order t order Step 1 1 Assess fetal status using electronic fetal monitor and review tracing. Explanation Fetal status must be reassuring to increase oxytocin rate. Fetal safety is priority. Your Correc order t order Step 2 2 Assess contraction pattern and palpate uterine resting tone. 3 3 Re-assess maternal vital signs. 4 4 5 5 Explanation To determine contraction pattern and the need to adjust oxytocin rate. Alteration in maternal vital signs can occur with increasing oxytocin dosages. Increase the oxytocin Assessment indicates by 2 mu/min per continued upward healthcare provider titration of oxytocin prescription. dosage. Praise woman and her Continued emotional husband for coping support assists couple in with contractions. achieving their goals for birthing experience.