Maternal Newborn Scenarios Jenny Theriot

Jenny TheriotRoom302 Jenny Theriot,30 y/o G1P0 at 31 weeks’ gestation. She has had an uncomplicated pregnancy until this morning when she woke up with clear fluid leaking from her vagina. She denies having contractions but says she isn’t really sure what she is feeling. She presents to the Obstetrics Triage Unit, looking distraught and crying, and says she doesn’t understand what is going on. You responded correctly to5out of6evaluations: Category Educational Needs Fall Risk Health change Pain level Physiological Needs Sensorium Needs Your response Increased acuity Increased acuity Increased acuity Normal acuity Increased acuity Normal acuity Explanation Status assessment reports leaking of fluid from vagina, possible contractions and and support for the client. Status assessment reports the client is pregnant; this changed her center of grav Status assessment reports leaking of fluid from vagina and possible contractions Status assessment does not indicate report of pain. Status assessment reports leaking of fluid from vagina, possible contractions. Status assessment reports no indication of changes in sensorium. Jenny Theriot 30 y/o G1P0 at 31 weeks’ gestation. She has had an uncomplicated pregnancy until this morning when she woke up with clear fluid leaking from her vagina. She denies having contractions but says she isn’t really sure what she is feeling. She presents to the Obstetrics Triage Unit, looking distraught and crying, and says she doesn’t understand what is going on. You correctly diagnosed10out of10options: Physiological Your Description Response Acute Pain False Anxiety True Impaired mobility, risk False for Impaired patterns of False elimination Infection, Risk for True Nausea Safety Description Deficient knowledge Disturbed sensory perception Fall, risk for Risk for injury, maternal/fetal False Explanat Status assessment indicates unknown status of contra Status assessment reports woman crying, stating she No indication at this time Status report does not indicate impaired elimination. Status assessment reports leaking of fluid from vagina membranes (SROM); risk for ascending infection and c Status assessment reports no indication of nausea. Your Response True False Expla Status assessment reports woman crying, uns to her. Status assessment reports normal sensory pe True True Client is pregnant and is at risk for falls related Status assessment reports possible SROM and Jenny TheriotScenario1 You enter the patient’s room. After washing and gloving your hands, you identify yourself and the patient, Mrs. Jenny Theriot. You assist her to change into a gown and place her on a triage stretcher in semi-Fowler’s position. 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 2 1 Establish therapeutic communication; review prenatal Establishes trust history with woman and events leading her to present patient care. to triage. 1 2 Assess vital signs, including temperature. Establishes base increases risk of increases as a sig 3 3 Perform Leopold’s Maneuver. Identify position difÏcult at 31 we 4 4 Apply external tocodynamometer and fetal transducer Detects and reco and palpate fundus to assess for contractions. intensity, detects fetal back. 5 5 Using a sterile gloved hand, test fluid leaking from Nitrazine paper d vagina with Nitrazine paper. (acidic). Jenny TheriotScenario2 Spontaneous rupture of membranes (SROM) confirmed by +Nitrazine test and collection of fluid with +Fern test. A Biophysical Profile (BPP) is performed to assess fetal status and amniotic fluid volume, which is found to be decreased. Amniotic fluid continues to leak from vagina. Orders are received to admit to Prenatal Unit and implement Prenatal Premature Rupture of Membranes (PPROM) protocol. An IV of 1000 ml D5W is started to ensure adequate hydration. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered2out of5actions: Your Correct order order Step 1 1 Place bed in Trendelenburg position. 3 2 4 3 2 4 5 5 Discuss plan of care with patient; answer questions honestly, especially concerning SROM and implications for preterm labor and birth. Assess support systems available to woman. Apply sequential compression device (SCD) boots and connect to machine. Begin Intake and Output (I&O) chart and document every shift. Jenny TheriotScenario3 Assists in relieving premature cervical continuing leaking Provision of clear in care and can allay Assistance and cari stressful events. Prevents the forma Ensures adequate h Mrs. Theriot continues on complete bedrest in Trendelenburg position. Upon entering her room she tells you that she “had a gush of fluid and feels like something came out of her vagina”. She also reports feeling hot and flushed and that she is not sure if her baby is moving as much as it was previously. 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 4 1 Inspect perineum. E Possible umbilical cord prolapse with Patient states she “feels like somethin prolapsed cord is the quickest assess Occult prolapse of umbilical cord cuts potential fetal death. Significant chan hidden or occult prolapsed cord. Increasing temperature indicates infe 2 2 Assess FHR for bradycardia. 1 3 5 4 3 5 Assess vital signs, including temperature. Assess for contractions; palpate On-going vigilance for signs of preterm fundus. detected by monitor or recognized by Assess for foul odor to amniotic Indicative of infection or chrioamnion fluid; perform pericare and provide fresh underpads. Jenny TheriotScenario4 Four days later Mrs. Theriot remains on bedrest and continues to leak small amounts of amniotic fluid. Assessment: BP 110/70 mmHg, P. 78 beats/minute, R 20 breaths/minute, T. 99.4o F. Due to the potential for developing chorioamnionitis, her healthcare provider is increasingly concerned about possible pre-term delivery and writes new orders for her continuing care. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered2out of5actions: Your Correct order order Step 4 1 Perform Non-Stress Test (NST) now and bi-weekly BPP and every shift; teach woman to do Daily Fetal Movement Counts (DFMCs). 2 2 1 3 3 4 5 5 Reactive NST indicative of fetal w fetal compromise. Biophysical Pro ultrasound to evaluate a babys he and amniotic fluid level. The NST signs of fetal compromise Administer Betamethasone 12 mg IM for Stimulates fetal lung maturity by two doses 24 hours apart. production or release of lung surf Administer a broad-spectrum antibiotic Treat infection, decrease incidenc (e.g., ampicillin, erythromycin) and additional 24 hours to elapse afte continue for 7 days. Request neonatologist to visit patient. Affords opportunity to discuss car anxiety. Assess results of daily CBC. Increasing WBC indicative of infec Jenny TheriotScenario5 Mrs. Theriot is weepy and says she is tired of being in bed and in the hospital. She is also having a hard time resting because of the multiple interruptions involved with her care. 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 5 1 Encourage vocalization of fear and concerns. 3 2 Cluster nursing care activities as much as possible, such as medication administration, assessments, and vital signs. 4 3 Offer diversional activities: watching TV, reading, crossword puzzles, small needlecraft activities. Request family to bring articles from home to “decorate” hospital room. 2 4 Teach conscious relaxation and breathing techniques. 1 5 Can help Promote interrup Assists i mobility “normal Non-pha and dec Provide comfort measures such as back rubs, position changes, Decreas and aromatherapy. feeling o