Maternal Newborn Scenarios Miranda Johnson

Miranda Johnson 32 y/o G3P2 at 39 weeks gestation. It has been 10 years since her last pregnancy. She was admitted to Labor & Delivery late last night in active labor. Upon admission, sterile vaginal exam (SVE) was 2 cm dilated, 80% effaced and -1 station (2/80/-1). She had small amount of bloody discharge, but membranes were intact. Contractions were every 3-4 mins., lasting 5080 secs., with reassuring fetal heart rate (FHR). She rated her pain as 3 on 010 pain scale and stated most of the pain was in her back and vaginal area. Ms. Johnson was weighed on admission at 250 pounds, she reported that she is allergic to penicillin, and has mild scoliosis. On admission, Ms. Johnson admitted that she does not tolerate pain well and wants an epidural like she had with her previous pregnancies. Her significant other is in the room on the couch playing games on his IPAD, and frequently texting on his phone. At 0630, her water broke (SROM-spontaneous rupture of membranes) and fluid was clear. SVE is 4 cm dilated, 90% effaced, and 0 station (4/90/0) with contractions every 2-3 mins., lasting 40-70 secs., with reassuring FHR. Pain level is 7-8 out of 10, and she became increasingly irritable, short tempered, and requested an epidural. IV fluids, 1000 ml of Lactated Ringers were infused at 125ml/hr. per order. There are signed orders for an epidural PRN (as needed). Miranda JohnsonRoom302 Miranda Johnson,32 y/o G3P2 at 39 weeks gestation. It has been 10 years since her last pregnancy. She was admitted to Labor & Delivery late last night in active labor. Upon admission, sterile vaginal exam (SVE) was 2 cm dilated, 80% effaced and -1 station (2/80/-1). She had small amount of bloody discharge, but membranes were intact. Contractions were every 3-4 mins., lasting 50-80 secs., with reassuring fetal heart rate (FHR). She rated her pain as 3 on 0-10 pain scale and stated most of the pain was in her back and vaginal area. Ms. Johnson was weighed on admission at 250 pounds, she reported that she is allergic to penicillin, and has mild scoliosis. On admission, Ms. Johnson admitted that she does not tolerate pain well and wants an epidural like she had with her previous pregnancies. Her significant other is in the room on the couch playing games on his IPAD, and frequently texting on his phone. At 0630, her water broke (SROM-spontaneous rupture of membranes) and fluid was clear. SVE is 4 cm dilated, 90% effaced, and 0 station (4/90/0) with contractions every 2-3 mins., lasting 40-70 secs., with reassuring FHR. Pain level is 7-8 out of 10, and she became increasingly irritable, short tempered, and requested an epidural. IV fluids, 1000 ml of Lactated Ringers were infused at 125ml/hr. per order. There are signed orders for an epidural PRN (as needed). You responded correctly to6out of6evaluations: Your respons Category e Explanation Educational Increase Status report indicates patients last pregnancy was 10 Needs d acuity years ago. Every pregnancy and labor are different therefore remedial labor and delivery education would beneficial. Patient also has mild scoliosis and weighs 250 pounds which could increase the difÏculty of epidural insertion. Proper positioning and breathing techniques during the epidural procedure may lead to decreased difÏculty of epidural insertion. Fall Risk Increase Related to pregnancy and changes in balance and d acuity center of gravity. Health Increase Related to active labor and change in health status. change d acuity Pain level Increase Related to increased pain level of 7-8 out of 10. d acuity Physiologic Increase Related to active labor, increased pain, and desire for Your respons Category e al Needs d acuity epidural. Sensorium Normal No indication. Needs acuity Explanation You correctly diagnosed6out of6options: Physiological Description Risk for Impaired Urinary Elimination Risk for Maternal Injury Safety Description Deficient knowledge Fall, Risk for Impaired maternal newborn bonding, Risk for Risk for Ineffective Coping Your Response True Related to fetal head p True Related to epidural ins Your Response True Client has not had a ch True Patient is term in pregn False No indication. False No indication. Miranda JohnsonScenario1 Upon entering patients’ room, wash hands, introduce self to patient and significant other. Check arm bands of both patient and significant other and compare with Medical Record. Note additional armband for medication allergies. Confirm allergies with patient. Explain POC (Plan of Care) regarding pain management, answer questions, and address patients’ concerns within scope of practice. Educate patient/family about the procedure used to insert the epidural catheter and PCEA (Patient Control Epidural Anesthesia) button. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered0out of5actions: Your Correc order t order Step 2 1 Review prenatal record with patient. Confirm pregnancy complications, allergies, and orders for epidural. 1 2 Witness signing of epidural informed consent It is the responsibility of eac patients prenatal record. All care. It is the responsibility of the Your Correc order t order Step by Anesthesiologist and patient AFTER preanesthetic evaluation. 5 3 Initiate IV bolus per order in preparation of epidural procedure. 3 4 Gather epidural medications to include Ephedrine, per Anesthesiologist orders, epidural tray, crash cart, nonrebreathing mask, O2 tubing, and suctioning equipment. 4 5 Monitor patient BP, Pulse, O2 Sat, and FHR during epidural procedure according to established guidelines. review and sign the Epidura patient’s signature. Consent care related to the epidural Helps to mitigate maternal blockade (epidural). Fluids s pre-hydrate client. Epidural analgesia can caus vasopressor, should be read Hypotension reduces the blo deprivation leading to a non with a nonrebreathing mask deprivation. o A severe reac arrest. A crash cart and suc during epidural infusion. Vital signs should be assess after epidural bolus, then ev MHR and FHR should be con lead to sympathetic blockad uteroplacental insufÏciency, Miranda JohnsonScenario2 At 0810 Ms. Johnson is resting comfortably with the HOB (head of bed) elevated 30 degrees with a right hip roll in place. She tolerated the epidural without difÏculty and now rates her pain as 2/10. She states she is feeling numbness in her vaginal area and down her legs bilaterally. Her sensory level is T10, and she moves all extremities without difÏculty. BP is 120/75 mmHg, HR=80 bpm, R=18 breaths/min., even & unlabored, and SpO2 is 98%. Contractions are every 2-3 mins., lasting 60-80 secs., moderate intensity per palpation, (+) Accelerations and (-) Decelerations with minimal Variability (Category 1). SVE is 7cm dilated, 95% effaced and 0 station. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered1out of4actions: Your Correct order order Step 3 1 Educate patient about the need for a urinary catheter. Insert Foley Catheter per protocol. 1 2 Assess maternal and fetal wellbeing using vital signs, fetal heart rate and other parameters. Ex Epidural analgesia decreases patients’ a to urinary retention. A full bladder will a Monitors maternal and fetal physiologica hypotension, oxygen deprivation, and in epidural insertion. Monitors physiologic Your Correct order order Step Ex 2 3 Encourage repositioning every Assists labor progression with fetal dece 30-60 mins. Keep HOB elevated elevation of at most 30 degrees to prev 30 degrees and hip roll in place. aortocaval compression. 4 4 Reassess patients’ understanding PCEA (patient controlled epidural analge of PCEA use. periodically according to the pump setti instructions should be given to both the the ONLY person authorized to push the Miranda JohnsonScenario3 At 0930 you are assigned another patient to triage and you ask a co-worker to watch over Ms. Johnson. At 1030 you assess Ms. Johnson who states “where have you been? I haven’t seen a nurse for the past hour!” Upon assessment you note that she is having trouble breathing and feels like she is going to pass out. BP =85/50mmHg, HR=120bpm, R=28, Sp02 = 89%, lung sounds clear per auscultation. Skin is pale and clammy, sensory level is T6, and she is unable to move her body from her chest down. FHR is 100 BPM with late decelerations, no accelerations and minimal to absent variability. Contractions are every 2-3 minutes lasting 70-80 seconds and strong to palpation. You ask your co-worker to notify both OB MD and Anesthesiologist to report current situation. 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 Turn epidural pump off. 3 2 Lower HOB, elevate foot of the bed, and reposition patient to left lateral position. 2 3 Rapid infusion (bolus) of IV fluids. Stops infusion of epidural medica Increases blood flow to the heart pressure. · Left lateral positioning increasing blood flow to the fetus Increases intravascular volume to Your Correct order order Step 5 4 Apply nonrebreathing oxygen mask Corrects fetal oxygen deprivation and set to 10L/minute per order. 4 5 Consider administration of Ephedrine. Vasopressors should be consider Miranda JohnsonScenario4 At 1130 after admitting the new triage patient, you enter Ms. Johnson’s room and notice Ms. Johnson continues to have episodes of hypotension with a nonreassuring FHR (Category 3). You ask your co-worker if she notified the OB MD and Anesthesiologist and she states that she did not have time. OB MD and Anesthesia are now notified by you and orders are received for a Stat C-Section. Signed informed Operative consent is on the chart. Ms. Johnson and her significant other are quickly educated on what to expect during the C-Section before being transferred to the OR. 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 Continually monitor maternal vital signs and fetal heart rate. 2 2 Administer Ephedrine per protocol for hypotension. 5 3 Notify the charge nurse and nursery Allows for continual assessment and possibility of additional nece Vasopressors are used for persist medication administration. Charge nurse will notify OR team Your Correct order order 1 4 3 5 Step personnel of STAT C-Section. Nursery nurses will notify Neonat impending delivery. Administer pre-op medications per Nausea and vomiting frequently anesthesia order. which could lead to aspiration. Offer reassurance and emotional Helps to reduce anxiety which ca support to both mother and significant from severe hypotensive event. other. Miranda JohnsonScenario5 Baby boy Johnson is born at 1150 and immediately admitted to the NICU. His APGAR scores are low, he is lethargic, and in respiratory distress. Ms. Johnson is recovered for one hour and transferred to Postpartum where she is discharged after 3 days. Baby boy Johnson remained in the NICU for 10 days. After laboring Ms. Johnson, you are assigned 2 more patients, and decide to finish your charting on Ms. Johnson at the end of the shift or when you come in the next day. While catching up on your charting, you do not remember the exact details of Ms. Johnson’s care. You document what you think happened and assume that you did everything according to protocol and written orders. You notice your co-worker charted on Ms. Johnson under your name and you do not have time to check to see if the charting is accurate. You have worked with this nurse for 2 years and assume her charting is accurate. At the age of 1, Baby boy Johnson exhibits developmental delays, abnormal muscle tone, and posture. He is diagnosed with CP (Cerebral Palsy). Ms. Johnson files a lawsuit for TEN MILLION dollars against both you and your hospital claiming NEGLIGENT care during her labor causing Baby boy Johnsons’ CP. The hospital legal team, DON, CNO, and your manager call you into a meeting to get your statement. You do not remember much about that day because it has been a year ago. All you remember is that it was busy with back to back patients. Upon review of Ms. Johnsons’ medical record, it is discovered that you were NEGLIGENT in the following: 1. Failure to monitor Ms. Johnson’s vital signs per protocol 2. Failure to monitor Baby Boy Johnson’s FHR rate according to protocol 3. Failure to intervene in a timely manner to correct Ms. Johnson’s hypotensive event 4. Failure to notify both the Anesthesiologist and OB MD per protocol 5. Failure to document interventions, vital signs, assessments, and FHR per protocol 6. False documentation. Ms. Johnson wins the lawsuit and you lose your job and nursing license due to your gross negligence. Nursing care actions in order: You correctly ordered0out of5actions: Your Correct order order Step 4 1 Maintain efÏcient, timely and continual factual and accurate documentation. 5 2 2 3 3 4 1 5 Exp Prevents possible documentation errors due and not documented in a timely manner, fa risk for getting a double dose of a medicati discontinuity in medical care. o Prevents la can be interpreted as a breach of duty in a Thoroughly document factual Medical Records are legal documents used and accurate information. improvised charting may be discovered and Discuss patient load with Communication is key to successful patient charge nurse. compromised with unrealistic patient loads Always sign out when Others can chart on your patient under you charting on a patient. and will be used against you in a medical m only defense. · NEVER let anyone chart und NEVER ASSUME ANYTHING ALWAYS be able to support documentation your care or the care of others. Ms. Susie SmithRoom303 Ms. Susie Smith,33 y/o G2P0 at 42 weeks’ gestation. She is single with a limited support system. She has just completed a Non-Stress Test (NST) which was interpreted as being Non-Reactive. Her obstetrician has now ordered an Oxytocin-Stimulated Contraction Stress Test (CST). Fetal membranes are intact. Ms. Smith also has a history of hypertension and a previous pregnancy loss at 18 weeks’ gestation. She is crying and states “I can’t lose another baby”. External tocodynamometer and fetal ultrasound transducer remain in place from the NST.