Swift River Week 1 Scenarios
Sarah Lane Room 301
Sarah Lane, Mrs. Sarah Lane is a 25 y/o G2P0 who is at 42 weeks gestation. Estimated fetal weight is 400
... [Show More] 0 Gm. She presents to the Maternal-Fetal Medicine Clinic today for a Non-Stress Test (NST). Her first pregnancy ended in a miscarriage at 10 weeks gestation. Her husband has accompanied her to every prenatal visit; they both appear anxious regarding the test and the health of their baby.
Category
Your
response Explanation
Educational Needs Increased acuity Status assessment reports anxiety regarding impending non-stress test and health of baby.
Fall Risk Increased acuity Client is 42 weeks pregnant and changes in center of gravity and balance increase risk for falls
Health Change Increased acuity Status assessment reports post-term pregnancy: testing determines whether intrauterine environment continues to support fetus.
Pain Level Normal acuity Status assessment does not indicate report of pain.
Psychological Increased Status assessment reports post-term pregnancy. Testing is used to determine
Needs acuity timing of delivery for women at risk for uteroplacental insufficiency
Sensorium Normal acuity Status assessment reports no indication of altered sensorium.
Kesha Jackson Room 302
Kesha Jackson, Patient 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 98.1 F, 36.7 C, 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 Status Assessment reports Client is at increased of fall due to changing center of gravity and balance.
Health Change Increased acuity Status Assessment reports in addition to the pregnancy, there are now additional health issues due to the preterm
labor.
Pain Level Increased acuity 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 Increased acuity Status Assessment reports no issues reported here.
Kesha Jackson
Patient 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 98.1 F, 36.7 C, 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.
You correctly diagnosed 12 out of 13 options: 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 True 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 True Status assessment reports Kesha has limited resources and is an adolescent without a strong support system.
Physiological
Description Your Response 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 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.
Sarah Lane
Mrs. Sarah Lane is a 25 y/o G2P0 who is at 42 weeks gestation. Estimated fetal weight is 4000 Gm. She presents to the Maternal-Fetal Medicine Clinic today for a Non-Stress Test (NST). Her first pregnancy ended in a miscarriage at 10 weeks gestation. Her husband has accompanied her to every prenatal visit; they both appear anxious regarding the test and the health of their baby.
You correctly diagnosed 11 out of 12 options:
Kesha Jackson Scenario 1
Kesha is currently on the fetal monitor undergoing a non-stress test. FHR is 130 baseline, moderate variability, no decelerations, but is not having accelerations, with some interruptions in the tracing. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: [Show Less]