A 42-year-old woman named Alice enters the triage unit. She states that she is 40 weeks pregnant, this is her second pregnancy. She had an abortion when she was 18 otherwise she has no other children. While completing the admission interview, you learn she is single and became pregnant through in vitro fertilization because she did not want to wait any longer to have a child as her clock was starting to count down. Her chart states that she was suspected of having gestational diabetes due to her fundus measuring large, however she tested negative. Alice states that she wanted to have a natural birth but had learned about nitrous oxide and thought she may try that. She has been having contractions since this morning starting about 7 minutes apart. Her water broke on her way to the car.
What is her GTPAL:
Based on this information what are your top priority assessments?
1.
2.
3.
What priority labs need to be done before delivery?
1.
2.
3.
She is currently 4 cm dilated and 50 % effaced. Her vital signs are Temp-97.8 , HR-80, RR-22, BP-124/80, O2 sat- 97%. She is put on a FHM and the fetus’s heart rate is strong at 135-150 bpm with good variation. Her contractions are about 4-5 minutes apart lasting about 90. You complete the Leopold maneuver and find feet kicking under the left breast. A smooth surface under the right breast with a soft point on the top, and a firm bulge at the base of her pelvis with the firm part of the head on the left and the soft parts of the face up near the arms.
What position is the baby in_________________________________________? What stage of labor is Alice in________________?
What are your priority interventions?
1.
2.
3.
Six hours go by and Alice is only dilated to 6 cm and 70% effaced. Alice is extremely distressed and in a lot of pain. She tells you that the contractions really hurt, and she is not sure she can do it without something more than the nitrous oxide. She had not considered what her other pain alternatives were and wants to know what her options are at this stage of the labor. What education would you give her on her pain management options would be at this stage?
She chooses to have an epidural placed. The anesthesiologist comes, and you help get Alice in the proper position to have the epidural placed.
What position are you going to help Alice get in to have this epidural placed?
Alice was able to get an epidural. What are your priority assessments after Alice has the epidural placed?
1.
2.
3.
During your post epidural placement assessment these are the vital signs you obtained: 97.8 , 90, 22, 100/65, 97%. The FHM read that the fetus’s heart rate dropped to 90-100 bpm but with good variation.
Based on these vital signs, what are your priority interventions for Alice and the fetus?
1.
2.
3.
Two hours after the epidural was placed Alice is 10cm dilated, 100% effaced, and feels the need to bare down.
What stage of labor is Alice in _________?
What are your priority interventions?
1.
2.
3.
After 40 minutes of pushing, Alice gives birth to a baby girl at 5:18pm.
For the next 2 hours what are your top priorities, differentiate between mom and baby?
1.
2.
3.
4.
5.
She is 8 lb. 15 oz. and is 22 inches long. At one minute the infant has blue extremities,
a HR 90, her arms and legs are flexed, her tone is poor, and she is not crying.
What is the APGAR at 1 minute?
What are your priority nursing interventions?
1.
2.
3.
At 5 minutes she continues to have blue extremities, a HR is now over 100, her arms and legs are
flexed, her tone is good, and she now has a good cry.
What is the 5-minute APGAR score?
Placenta is delivered 15 minutes after the baby is born.
What do you need to look for when observing the placenta?
It is two hours after delivery and Alice is now ready to be transferred to the post-partum floor.
Please write your nursing note from your shift with Alice below:
Complete your SBAR for the admitting nurse on the post-partum floor.
S
B
A
R