CASE SCENARIO: You are assigned at the Labor and Delivery Room in your 4th Rotation in Ilocos Training and Regional Medical Center (ITRMC). Your Clinical Instructor assigned and instructed you to assists and to monitor the vital signs of the mother especially the blood pressure and the fetal heart tone of the baby. HISTORY: Cherry Blossom is a 30-year-old woman who is a G2 P0 has been admitted to labor and delivery at 39 weeks after her membranes ruptured at home. Her first baby was born vaginally 2 years ago. She was diagnosed with gestational diabetes at 28 weeks and has been on insulin during the last trimester. Her records indicate that she is carrying a single pregnancy in vertex presentation via ultra-sound. Her past medical history is uncomplicated, she has no allergies and she take no medication other than the prenatal vitamins (folic acids and Iron supplements). Her most recent vital signs minutes ago were as follows: BP 110/70, Pulse 69 beats per minute, Respiratory rate of 20 breaths per minute and Temperature of 36.8 C. In the delivery room the mother has been pushing for 2 ½ hours and is becoming exhausted. (“I am so tired” I can’t push anymore!”) The doctor ordered IVF of PLR 1 liter with incorporation of 10units oxytocin (1ampule) due to prolonged labor. Fetal heart tones has been uncomplicated (120 to 140 bpm). Her contractions occurred every 2 to3 minutes lasting 60 seconds, strong to palpation. Her blood sugars have all been less than 90 mg/dl, so her insulin drip has been on hold for the last couple of hours. As the baby crowns, the fetal heart rate accelerates to the 150 bpm with pushing. There is fluctuation of FHR but within normal limits. The doctor decided to have an episiotomy due to prolonged labor secondary to large baby and cord loop. The baby was delivered with an initial assessment of the following: acrocyanosis, RR of 42, HR of 98bpm, cries strongly with active movements and with thin meconium stains. The mother’s vital signs are as follows: BP 130/80 PR 110bpm, RR 25bpm and Temp 36.6. The mother was ok but tired and restless. The newborn care was done and the baby was given erythromycin ointment prophylaxis, Vit.K 0.05ML IM and Hepatitis B vaccine 0.1ML via intramuscular route and BCG vaccine Intradermal. Formulate 1 Nurses Notes (documentation)for your Newborn patient using the FDAR format. Integrate your nursing care interventions significant to bioethical and legal standards in patient care
CASE SCENARIO:
You are assigned at the Labor and Delivery Room in your 4th Rotation in Ilocos Training
and Regional Medical Center (ITRMC). Your Clinical Instructor assigned and instructed
you to assists and to monitor the vital signs of the mother especially the blood pressure
and the fetal heart tone of the baby.
HISTORY:
Cherry Blossom is a 30-year-old woman who is a G2 P0 has been admitted to labor and delivery
at 39 weeks after her membranes ruptured at home. Her first baby was born vaginally 2 years
ago. She was diagnosed with gestational diabetes at 28 weeks and has been on insulin during
the last trimester. Her records indicate that she is carrying a single pregnancy in vertex
presentation via ultra-sound. Her past medical history is uncomplicated, she has no allergies
and she take no medication other than the prenatal vitamins (folic acids and Iron
supplements).
Her most recent vital signs minutes ago were as follows: BP 110/70, Pulse 69 beats per minute,
Respiratory rate of 20 breaths per minute and Temperature of 36.8 C.
In the delivery room the mother has been pushing for 2 ½ hours and is becoming exhausted.
(“I am so tired” I can’t push anymore!”) The doctor ordered IVF of PLR 1 liter with incorporation
of 10units oxytocin (1ampule) due to prolonged labor. Fetal heart tones has been
uncomplicated (120 to 140 bpm).
Her contractions occurred every 2 to3 minutes lasting 60 seconds, strong to palpation. Her
blood sugars have all been less than 90 mg/dl, so her insulin drip has been on hold for the last
couple of hours.
As the baby crowns, the fetal heart rate accelerates to the 150 bpm with pushing. There is
fluctuation of FHR but within normal limits. The doctor decided to have an episiotomy due to
prolonged labor secondary to large baby and cord loop. The baby was delivered with an initial
assessment of the following: acrocyanosis, RR of 42, HR of 98bpm, cries strongly with active
movements and with thin meconium stains. The mother’s vital signs are as follows: BP 130/80
PR 110bpm, RR 25bpm and Temp 36.6. The mother was ok but tired and restless.
The newborn care was done and the baby was given erythromycin ointment prophylaxis, Vit.K
0.05ML IM and Hepatitis B vaccine 0.1ML via intramuscular route and BCG vaccine Intradermal.
Formulate 1 Nurses Notes (documentation)for your Newborn patient using the FDAR
format. Integrate your nursing care interventions significant to bioethical and legal standards in patient care.
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