Maternal Newborn Scenarios Cindy Mason

Cindy MasonRoom304 Cindy Mason,28 y/o G2P1 at 40 weeks gestation. She and her husband present to OB Triage with complaint of early labor. Her prenatal history indicates an uncomplicated first pregnancy with a spontaneous vaginal delivery. Her current pregnancy has also been uncomplicated with no risk factors identified. She and her husband have attended Lamaze Prepared Childbirth classes and their Birth Plan indicates a desire for an unmedicated labor and birth and breastfeeding. Mrs. Mason states her contractions are occurring every 4 minutes and lasting 60 seconds. She is using slow-chest breathing and rates her pain at 4/10. She also reports leaking clear fluid from her vagina. She believes the leaking began about two hours ago. You responded correctly to6out of6evaluations: Your Category response Educational Needs Increased acuity Fall Risk Increased acuity Health Change Increased acuity Pain Level Increased acuity Psychological Increased Needs acuity Sensorium Normal acuity Explanation Status assessment reports attendance at Lamaze classes and previous vagina management Client is at full term of pregnancy and has a changed center of gravity. Status assessment reports active labor with possible spontaneous rupture of m Status assessment reports frequent contractions with pain score 4/10. Status assessment reports active labor with desire for unmedicated labor and Status assessment reports no indication of increased sensorium acuity or chan Cindy Mason 28 y/o G2P1 at 40 weeks gestation. She and her husband present to OB Triage with complaint of early labor. Her prenatal history indicates an uncomplicated first pregnancy with a spontaneous vaginal delivery. Her current pregnancy has also been uncomplicated with no risk factors identified. She and her husband have attended Lamaze Prepared Childbirth classes and their Birth Plan indicates a desire for an unmedicated labor and birth and breastfeeding. Mrs. Mason states her contractions are occurring every 4 minutes and lasting 60 seconds. She is using slow-chest breathing and rates her pain at 4/10. She also reports leaking clear fluid from her vagina. She believes the leaking began about two hours ago. You correctly diagnosed7out of8options: Physiological Description Fatigue Related to Energy Expenditure Required for Labor and Coping Skills Impaired Comfort Infection, Risk Nausea Risk for Fluid Volume Deficit Risk for Impaired Urinary Elimination Your Response True Status assessment reports fr techniques True Status assessment reports fre techniques and report of pain True Status assessment reports po increasing risk for infection fo False Status assessment does not i False Status assessment does not i True Status assessment indicates bladder Safety Description Deficient knowledge Disturbed sensory perception Your Response Explan True Status report indicates attendance at childbirth cl variety of coping skills False Status assessment indicates no disturbance in se Cindy MasonScenario1 After washing your hands, introduce yourself to the patient, Mrs. Cindy Mason, and her husband. You escort her to a triage bed and hand her a gown to change in to. 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 3 1 Review prenatal history with patient and Birth Plan. 4 2 1 3 2 4 Explanation Allows for planning and implementation of patient care, ensures measures implemented are within Birth Plan and agency policy and should be done first. Obtain maternal vital According to stage and signs. phase of labor. Establishes baseline and on-going tolerance to labor process. Perform Leopold’s Identify position of fetus Maneuver. and location of fetal back to apply fetal and contraction monitoring. Apply fetal transducer Detects and records and external uterine contractions; tocodynamometer and assesses contraction palpate fundus during intensity. Detects and contractions. records FHR which is best heard through fetal back. Your Correc orde t r order Step 5 5 Perform a Sterile Vaginal Exam. Explanation Assesses dilation, effacement, station and status of fetal membranes. Cindy MasonScenario2 Client’s assessment findings: BP 110/70 mmHg, P. 86 bpm, R. 22 breaths/minute, T 97.8o F., SAO2 100%, contractions every 3 minutes, lasting 60 seconds, moderate intensity per palpation, FHR 140 baseline, moderate variability, + accelerations (Category 1). Sterile vaginal exam: 5 cm, 90%, -1 station, spontaneous rupture of membranes confirmed with a positive Nitrazine, slight bloody show, pain 4/10. Healthcare provider was notified of assessment and orders are received to admit to the LDR with ice chips and clear liquids allowed. Mrs. Mason is transferred to the LDR and report given to labor nurse. Mrs. Mason states that the contractions are getting stronger and requests suggestions on additional coping techniques. 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 Assess fetal status and contraction pattern The fetus is the first pr Your Correct order order 5 2 4 3 2 4 3 5 Step according to stage and phase of labor. Reassess maternal vital signs, including temperature; assess temperature every two hours. Assess color and character of amniotic fluid. Encourage ice chips and clear liquids such as apple juice, popsicles. Encourage frequent position changes and hydrotherapy in shower and birth as well as lab The nurse should then labor; risk for infection Amniotic fluid should b fluid indicative of pote Facilitates hydration a Comfort and relaxation Cindy MasonScenario3 Two hours later Mrs. Mason is using shallow-chest breathing to cope with contractions. Assessment findings: BP 120/80 mmHg. P. 90 R 26; contractions are every two minutes, lasting 65 seconds, strong to palpation; moderate bloody show with clear amniotic fluid; pain rated at 6/10, c/o increasing back pain. Sterile vaginal exam: 8 cm, 100%, 0 station. 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 2 1 Praise her efforts and tell her that she is almost ready to deliver Decrease anxiety an Decreasing anxiety nursing action. Your Correct order order Step 5 2 Encourage her to void at least every two hours 1 3 3 4 4 5 Avoid bladder disten comfort. Assist her with peri-care and change underpads as Provides comfort an needed Teach husband how to apply counter-pressure to Relieves back pain t woman’s back during contractions while sitting on position; encourage birthing ball. encourage fetal des Continue to provide comfort measures and Decrease discomfor minimize distractions in room techniques Cindy MasonScenario4 Mrs. Mason calls out and states she has an urge to push. She is doing pantblow breathing and is sitting on the birthing ball. Assessment findings: BP 128/78 mmHg, P. 90 beats/minute, R, 28 breaths/minute, FHR 144 baseline with moderate variability, +accelerations, no decelerations (Category 1). Sterile vaginal exam: 10 cm, 100%, +1 station. Her healthcare provider is present and ready for delivery. 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 Assist woman to birthing bed and place in lithotomy or side-lying position for birth. 2 2 Request assistance for room set up and for Side-lying decreases p stretching; optimal for first. The room must be set Your Correct order order 3 3 4 4 5 5 Step delivery. Ensure neonatal resuscitation equipment readily available. Encourage woman to push spontaneously when she feels the urge to do so rather than directed pushing Encourage deep breaths and relaxation inbetween each contraction personnel for a safe de Always anticipate neon assessments during lab Less fatigue and enhan trauma, less risk for fet maneuver with directe Conserves energy, mai fetus, thereby maintain Cindy MasonScenario5 Mrs. Mason has an uncomplicated, spontaneous vaginal delivery of an 8 pound baby girl. Mom and Dad are overjoyed and admiring their new baby girl. Placenta was delivered spontaneously. No vaginal or perineal lacerations were identified. 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 Perform an Apgar Score on infant at 1 and 5 minutes of birth. 2 2 Place the infant in skin to skin contact with mother. 3 3 Reassess maternal vital signs. 4 4 Reassess uterine fundus for tone and location, if boggy massage till firm. Rapid assessment of newborn’s signs that indicate newborn’s p Prevents evaporative heat loss; promotes maternal-infant bond Monitors physiologic response t A firmly contracted uterus clam preventing uterine atony and ex Your Correct order order Step 5 5 Reassess lochia for amount and color; Post-birth uterine discharge is i note any clots or odor. steadily decreases and should b