NURS 320 - Maternal Newborn. Complete Study Guide.
Jennifer Humes Room 301
Jennifer Humes, 30-year-old Caucasian female, G4 T2 P0 A1 L2, 33 5/7 weeks
... [Show More] gestation. History of chronic hypertension and gestational hypertension with this pregnancy. Nifedipine XL 30 mg daily. NKDA. Previous pregnancies uncomplicated with NSVDs. One spontaneous abortion at 10 weeks gestation. Woke up early morning feeling wet; wasn’t sure if leaking urine or membranes ruptured. Turned on light and it was blood. Asked a neighbor to come over to watch other children and husband brought her to hospital. They are making phone calls to get family member to come and take care of 5 and 2-year old children. Anxious about this pregnancy and bleeding too. Has mild abdominal pain and contractions.
You responded correctly to 5 out of 6 evaluations:
Category Your response Explanation
Educational Needs Increased acuity Status assessment reports r/t change in condition.
Fall Risk Increased acuity Status assessment reports r/t 34 weeks gestation and pain, change in center of gravity.
Health change Increased acuity Status assessment reports r/t complication of pregnancy and bleeding.
Pain level Increased acuity Status assessment reports r/t abdominal pain and mild contractions.
Physiological Needs Increased acuity Status assessment reports r/t concern about condition and care of other children.
Sensorium Needs Normal acuity Status assessment reports no problems related to sensorium indicated in the report.
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.
Category
Your
response Explanation
Educational Needs
Increased acuity
Status assessment reports leaking of fluid from vagina, possible contractions and preterm delivery. These should be the subject of teaching and support for the client.
Fall Risk Increased acuity
Health change Increased
acuity
Pain level Decrease acuity
Status assessment reports the client is pregnant; this changed her center of gravity and balance. Status assessment reports leaking of fluid from vagina and possible contractions.
Status assessment does not indicate report of pain.
Physiological Needs
Sensorium Needs
Increased acuity
Normal acuity
Status assessment reports leaking of fluid from vagina, possible contractions. Status assessment
Kesha Jackson Room 303
Kesha Jackson, Kesha Jackson is a G1P0, gestational age of 33.1. She came in complaining of contractions for 2 hours that are now every 5 mins. She is unsure about rupture of membranes, denying vaginal bleeding and recent intercourse. She states the baby is active. She rates her pain an 8/10. Her current vital signs are 98.1o F., 92 BPM, 16 breaths/min, 122/64 mmHg, 99% on room air. The fetal heart rate is 135 baseline but is not yet reactive. Cervical exam reveals that she is not dilated or effaced, and the baby’s head is not engaged in the pelvis. She has no medical history and NKA. In obtaining her history, it was learned that she is 15 years old, currently homeless, and has been staying with various friends. She does have some supplies including diapers, wipes, and some clothing that she received from a friend. She expresses the desire to take her baby home with her. She is receptive to teaching and assistance she just has been unsure of how to obtain it. She came to the OB triage via a bus.
Category
Your
response Explanation
Educational Needs
Increased acuity
Status Assessment reports Kesha will need a lot of education regarding preterm labor precautions, resources for assistance, and caring for her baby once it arrives
Fall Risk Increased acuity
Health Change Increased
acuity
Pain Level Increased acuity
Status Assessment reports Client is at increased of fall due to changing center of gravity and balance.
Status Assessment reports in addition to the pregnancy, there are now additional health issues due to the preterm labor.
Status Assessment reports she rates her pain an 8/10
Psychological Needs
Increased acuity
Status Assessment reports Kesha is homeless, is pregnant, is a teen with developing coping mechanisms, and has a lack of a consistent support system.
Sensorium Normal acuity
Status Assessment reports no issues reported here.
Saftey
Description
Your
Response Explanation
Fall Risk True Status assessment reports Client is pregnant with a changing center of gravity
and balance, increasing risk for falls.
Ineffective health maintenance
True Status assessment reports Client has limited resources and several barriers to health and healthcare.
Infection False Status assessment reports no signs of infection noted.
Knowledge Deficit True Status assessment reports Client does require teaching about resources,
childcare and preterm labor plan of care.
Psychological
Description
Your
Response Explanation
Anxiety False No indication
Impaired home maintenance
True Status assessment reports Client is currently homeless and with limited resources.
Noncompliance False Status assessment reports she has been complaint and is willing to learn and
perform the necessary steps to get help.
Risk for impaired parenting Physiological
True Status assessment reports Kesha has limited resources and is an adolescent without a strong support system.
Description
Your Respons
e Explanation
Acute Pain True Status assessment rates pain 8/10
Decreased cardiac output
False Status assessment reports status does not reflect issues with cardiac output at this time.
Impared Mobility False Status assessment reports No mobility issues have been identified. Nausea False Status assessment reports No reports of nausea.
Risk for nutritional imbalance
Scenario 1
Your
True Status assessment reports adolescents who are pregnant are at higher risk for nutritional deficiencies due to supporting their growth as well as fetal growth.
orde r
Correc
t order Step Explanation
4 1 Assure that the monitor
is tracing fetal heart rate consistently.
3 2 Adjust fetal heart rate monitor.
1 3 Give mother some cold
juice to drink.
2 4 Reposition mother to
left lateral position.
5 5 Request ultrasound for
biophysical profile.
It is important to make sure that you are tracing FHR and not maternal, and that the tracing is consistent. There could be accels that are not showing up due to an inconsistent or interrupted tracing.
Adjusting FHR monitor can allow for clearer tracing and may also stimulate the fetus which might aid in obtaining accelerations.
Cold, sugary drinks will often increase fetal heart rate and activity. It is important to have already established a good tracing.
Repositioning mother results in fetal repositioning which may increase accelerations. However, it often makes tracing more difficult so should not be done before other easier and more efficient interventions.
A biophysical profile can assess overall fetal status if NST is not reactive or tracing is difficult to maintain/other interventions to obtain NST ineffective. It is more time consuming and expensive so should not be used before other interventions.
Scenario 2
Your
orde r
Correc
t order Step Explanation
1 1 Assess FHR and contraction
pattern per monitor.
The presence of contractions is an indicator of preterm labor. It is important to assess the frequency and intensity of contractions. It is always imperative to monitor FHR status to assess fetus.
2 2 Perform sterile cervical exam A sterile cervical exam will reveal how advanced the preterm labor is.
to determine dilation, effacement, and station.
4 3 Obtain urinalysis and lab
work such as CBC.
3 4 Administer IV fluids and/or
antibiotics.
5 5 Consider administration of
tocolytics.
Scenario 3
Your Correc
If significant cervical change is present, magnesium sulfate for neuroprotection and tocolysis should be considered.
Obtaining Urinalysis and lab work can point to potential causes for preterm labor such as dehydration or infection. This will guide your treatment.
Administering fluids and/or antibiotics would be determined after an assessment and lab work have been completed and have pointed to a potential cause.
Tocolytics should be considered if other interventions have failed. There are more potential side effects from tocolytics than fluids and antibiotics. Tocolytics will also be less effective if the cause is infection or dehydration
orde r
t
order Step Explanation
1 1 Educate Kesha about steroids and the need Patients should always be educated before being given a
to administer them. Verify that she understands the rationale to receive the medication using the teach back method.
new medication. They should have an understanding of the medications side effects and reasons for giving it and express their understanding and consent prior to administration.
3 2 Verify the 5 rights of medication The 5 rights should always be verified prior to giving a
Your Correc
orde r
t
order Step Explanation
administration. medication.
2 3 Prepare steroids as ordered by the healthcare provider.
4 4 Choose large muscle for injection and offer ice to site.
5 5 Establish a plan with Kesha to receive the second required dose of steroids in 24 hours. If discharged, she may have trouble getting transportation and need assistance.
Scenario 4
The medications should be given after education, consent, and 5 rights have been completed.
Steroid injections should be given deep IM and may be painful, so ice should be offered.
Steroids should be given in 2 doses, 24 hours apart. It is important to establish a means for Kesha to get her second dose. This is after the previous steps.
Your order
Correct
order Step Explanation
2 1 Use therapeutic communication.
1 2 Allow her to express her
feelings and concerns.
4 3 Ask open ended questions to
further develop the conversation.
3 4 Answer any questions openly
and offer support.
Therapeutic communication should always be used when speaking with patients.
It is important to allow her to express herself and explain what she is experiencing.
After the initial communication by the patient, attempt to develop the conversation further by asking open ended questions and see if she has more to communicate.
Answering questions and providing more information is important while you are in a teachable moment. Offer support for her and encouragement as well.
5 5 Document the conversation. Documentation should be done last to include all elements of the
conversation. [Show Less]