Maternal Newborn Scenarios Jessica Wu

  .  Jessica WuRoom304 Jessica Wu,35-year-old Asian female, G3 T2 P2 A0 L2, 35 weeks gestation. NKDA. Previous pregnancies uncomplicated but Cesarean births due to persistent breech position. Smoker x 15 years but states she “cut back to 3 cigarettes/day during her pregnancies.” Reports that she started smoking during college. States started having moderate amount of bright red bleeding about 0800. Came to the hospital after dropping the older children at school (5 and 7 years old). She has called her husband and he is meeting her at the hospital because he was already at work. It is now 0945. She is anxious about the bleeding. States she “never had anything like this with her other pregnancies!” Denies pain, contractions, or leaking of amniotic fluid. You responded correctly to6out of6evaluations: Category Educational Needs Fall Risk Health Change Pain Level Psychological Needs Sensorium Your response Explanatio Increased acuity Increased acuity Increased acuity Normal acuity Increased acuity Normal acuity Status assessment reports r/t change in condition and bleeding Status assessment reports r/t 35 weeks gestation (third trimester and c Status assessment reports r/t complication of pregnancy and bleeding. Status assessment reports No pain or contractions noted in the report. Status assessment reports r/t concern about condition and stress relate Status assessment reports alert and oriented X4. Drove herself to hosp Jessica Wu 35-year-old Asian female, G3 T2 P2 A0 L2, 35 weeks gestation. NKDA. Previous pregnancies uncomplicated but Cesarean births due to persistent breech position. Smoker x 15 years but states she “cut back to 3 cigarettes/day during her pregnancies.” Reports that she started smoking during college. States started having moderate amount of bright red bleeding about 0800. Came to the hospital after dropping the older children at school (5 and 7 years old). She has called her husband and he is meeting her at the hospital because he was already at work. It is now 0945. She is anxious about the bleeding. States she “never had anything like this with her other pregnancies!” Denies pain, contractions, or leaking of amniotic fluid. You correctly diagnosed7out of12options: Physiological Description Acute Pain Decreased Cardiac Output Deficient Fluid Your Response Explanat False Status assessment reports no current pain. False Status assessment reports not enough evidence in ass Client is alert and providing history during admission i True Status assessment reports Blood loss r/t vaginal bleed Description Volume, risk for Ineffective tissue perfusion Injury, risk for fetal Safety Your Response False True Explanat Status assessment reports Not enough evidence in as (would be at risk for) Status assessment reports r/t risk for fetal hypoxia Your Description Response Fall Risk True Injury, risk for maternal True Love and Belonging Description Anxiety Disabled Family Coping Fear Grieving, risk for Health Maintenance; Ineffective Expla Status assessment reports r/t shifting center of g Status assessment reports r/t risk for hypovolem Your Response Explana True Status assessment reports r/t unknown impact of curr False Status assessment reports no evidence. Husband on False True True No indication at this time Status assessment reports r/t actual or perceived thre Status assessment reports r/t deficient knowledge ab health maintenance will need to change with health c Jessica WuScenario1 After obtaining report as above the nurse also learns that Jessica is O-, Rubella immune, and was Group B Strep negative with previous pregnancies. Her hemoglobin level was 11.5 g/dL with a hematocrit of 34.5% at 28 weeks gestation. All of the other lab findings are normal. The nurse enters Jessica’s room to begin the initial shift assessment. Her husband, Dan, is now at her side. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered2out of5actions: Your Corre orde ct r order Step 1 1 Wash hands and introduce self to the client and her husband. 4 2 2 3 Explanation Washing hands upon entering the room is a priority for prevention of infection. Introductions before touching the client is professional behavior. Obtain her vital The first action should be signs, fetal heart determining the stability of tones, presence or the mother and fetus. A absence of change in status can often be contractions, and detected by a change of vital perform a pain signs or fetal heart tones. assessment for Vital signs may be normal, abdominal even with heavy blood loss. A tenderness. pregnant woman can lose up to 40% of her blood volume without showing signs of shock. Because she had previous pregnancies, there is a risk for uterine rupture, previa, or abruption. Educate the client The degree of vaginal about the status of bleeding is an important part the fetal heart of the nurse’s assessment. tones. The assessment of private areas should be performed later in the examination if the client is stable. When Your Corre orde ct r order 3 4 5 5 Step Explanation assessing for vaginal bleeding, ask the client to lift her bottom completely of the bed so that the nurse can observe for blood loss beneath the buttocks. Apply gloves and The degree of vaginal assess perineal bleeding is an important part pad for bleeding, of the nurse’s assessment. estimate blood The assessment of private loss, and ask her areas should be performed to save all pads. later in the examination if the client is stable. When assessing for vaginal bleeding, ask the client to lift her bottom completely of the bed so that the nurse can observe for blood loss beneath the buttocks. Offer peri-care and Before leaving the room, the ask the client not nurse should assess and to get out of bed intervene for safety, placing without assistance. the call light in reach and teaching about the risk for injury and need to stay in bed. Peri-care provides patient comfort. Jessica WuScenario2 The nurse completes an initial assessment. T 36.6 C, 97.8 F; P 96 beats/minute, regular; R 20 breaths/minute, regular; BP 128/84 mmHg; FHR 125, moderate variability, 2 accelerations to 145 in 20 minutes. No contractions on EFM. Normal resting tone. Abdomen soft, nontender. Fundal height measures 37 cm. Urine negative for protein on dipstick. States that the current pad is the first pad applied at home. 15 cm saturation bright red blood on pad, no clots. Nonpitting pedal edema. DTR +2 bilaterally. The healthcare provider is notified of the assessment and the following orders are given. The client and her husband are educated about each of the orders. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered6out of6actions: Your Correct order order Step 1 1 Assist client to assume a sidelying position. 2 2 CBC, Chemistry Panel, Type and Screen, Ultrasound/Biophysical Profile. 3 3 Continuous EFM. Vital Signs q 15 minutes. 4 4 5 5 6 6 Ex Left lateral recumbent position decreases venous return, placental and renal perfus Contact the lab to come and draw these minutes and will drive the plan of care fo placenta previa and abruptio placenta. B Initial vital signs were recorded on admis maternal age, client is at risk for preecla could indicate intravascular fluctuations concerned about fetus. Hearing fetal hea her VS. Verifies fetal wellbeing. EFM has tocotransducer may need to be adjusted IV 18 gauge lactated ringers at At least one IV (large bore in case blood t 150 mL/hour. for blood replacement as needed. Rh immunoglobin 300 mcg IM. This client is Rh negative so she is a cand Rh negative receive the Rh immunoglobi maternal blood, in case there was an exc circulation during the bleeding of the pla IM betamethasone 12 mg q24 hr . IM steroid injections would be given to e X2. than 34 weeks. Neonatal benefit is maxim injection and birth is longer than 48 hour would not receive this injection, although may benefit from use of steroids. Jessica WuScenario3 Ultrasound shows a partial posterior placenta previa. Biophysical profile 10/10 and normal Amniotic fluid volume. Chem Panel normal. Hgb 10 g/dL and HCT 30%. Platelets 160,000. The nurse admits the client for expectant management of placenta previa. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: Not all interventions should be completed You correctly ordered6out of6actions: Your Correct order order Step 1 1 Assist client to lateral positioning. 2 2 3 3 4 4 5 5 6 6 Client is actively bleeding so lateral could disrupt clot formation and he Maintain I & O. Bring scale into room Weighing pads most accurately det and weigh all pads. weight) equals 1 mL of blood loss. I Bring extra pillows to enhance Enhancing comfort in the side-lying comfort in side-lying position and position. Side-lying decreases press place between knees, behind back, placental and renal perfusion. and under abdomen. Bring bedpan, graduated cylinder into The nurse may include I&O in the c room. urine output demonstrates minimal renal perfusion. Blood loss would be documents positive or negative flui better indication of acute blood loss Educate client and husband about 24- Educating and involving the client a hour urine collection, I&O and decrease anxiety and empower the documenting oral intake. team. Education occurs after other Prepare to assist with a vaginal exam Vaginal exams should not be done to cervical changes. and disrupt clot formation. This clie imminent. Vaginal exam is contrain not be completed. Jessica WuScenario4 The client’s condition stabilized and bleeding stops. After 48 hours, she is discharged to home with the following instructions. The nurse selects instructions as part of the nursing actions. 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 If bleeding resumes, return to the hospital immediately. 2 2 3 3 4 4 5 5 E Placenta previa should always be co massive blood loss with resulting hy resumes. The client needs to recogn hospital. Keep all appointments for prenatal In order to assure maternal and feta visits, fetal assessments, and lab surveillance will be needed. Appoint tests. to discharge. Ensure the client lives within a short In order for this client to be discharg distance from the hospital and has client should be instructed to call 91 constant access to transportation. Discuss willingness to comply with Bedrest will be challenging with two activity restrictions: bedrest with her family and friends to be complia bathroom privileges and “pelvic to be explained as no intercourse, n rest”. nothing inserted into the vagina. Discuss diversionary activities and Once stabilized, this client will feel g provide resources for coping with restrictions is common. Ideas for div bedrest. assist the client in remaining compl Jessica WuScenario5 Two weeks later, Jessica returns to the hospital. She is now 37 weeks gestation. She says, “I woke up in a puddle of blood this morning. I wasn’t doing anything! I’m not having any pain or contractions.” Her husband says he called her doctor and the doctor is meeting them at the hospital. 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 Call for assistance but do not leave client. Keep family informed of situation. Stay calm and give emotional support. 2 2 Obtain her vital signs, fetal heart tones, and perform a pain assessment. 3 3 Administer oxygen via nonrebreather mask at 10 L/min. 4 4 5 5 Insert 18 gauge IV with normal saline solution and send CBC, coagulation panel, and Type and screen. Insert indwelling catheter. E Staying with the client develops trust will decrease when the client is inform unknown. Anxiety is highly contagiou calm and provides emotional support . The first action should be determini baby. A change in status can often be heart tones. Enhance oxygenation to the materna 100% oxygen. This action helps both and insert an indwelling catheter. At least one IV (large bore in case blo loss and for blood replacement prn. L Continuous measurement of urinary o maternal organ perfusion. A retention prepares the client for cesarean birth fetus is in a breech position, she wou previous cesarean births. Almost all w cesarean.