Case Studies, Chapter 11, Maternal Adaptation During Pregnancy Rulings PDF

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RNSG 2162 MATERNAL HEALTH CLINICAL OB CASE STUDY #1

Case Studies, Chapter 11, Maternal Adaptation During Pregnancy 1. Jessica and Mike are new clients at your obstetrics office. You are asking them about the reason for their visit. Jessica says she thinks she is pregnant because she missed a period. Mike tells you Jessica is always nauseated in the morning and eats all the time the rest of the day. They have not been using birth control and have wanted to have children since they got married last summer. Jessica says her clothes are feeling tighter and her breasts seem tender. Mike says he has noticed that Jessica has been frequently getting up to go to the bathroom at night. (Learning Objectives 1, 2, and 3) a. What subjective symptoms have led Jessica and Mike to presume she is pregnant? Subjective symptoms would be amenorrhea, breast tenderness, urinary frequency, clothes feeling tighter (weight gain) and nausea in the morning and eating all the time the rest of the day. What other conditions could be the cause of Jessica’s symptoms? The other condition which could be suspected is a premenstrual syndrome where women experiences symptoms similar to pregnancy. The frequent visits to bathroom can be due to urinary tract infection. How can a pregnancy be confirmed as probable? A pregnancy can be confirmed as probable by not having used birth control measures since wedding, having abdominal enlargement, positive pregnancy test, Goodell’s sign, Chadwick’s sign, Hegar’s sign, Braxton Hicks contractions and Ballottement at 16 to 28 weeks gestation. Diagnosed as positive? A pregnancy can be diagnosed as positive with an ultrasound verification of embryo or fetus, auscultation of fetal heart tones via Doppler and fetal movement felt by experienced clinician at 20 weeks gestation. b. Discuss the nutritional needs of Jessica and her baby. Nutritional needs of Jessica and her baby are she will need to consume more of each type of nutrients during her pregnancy for direct effect of nutritional intake. Will need to take prenatal vitamins with folic acid to help prevent neural tube defects and to help the well-being of her and the baby. Increase intake in protein, iron, folate and calories as directed by provider according to maternal healthy weight gain BMI. Use of USDA’S Food Guide. Avoidance of some fish due to mercury content, raw fish, raw eggs, organ meat such as liver, caffeine, spicy oily foods and unwashed produce. Increase hydration by drinking more fluids such as water and avoiding sodas. No alcohol, smoking or tobacco use. 2. Beth (age 18) is experiencing her first pregnancy and is now 24 weeks gestation. She tells you that she is “amazed by the changes that have happened to my body already.” Beth wants to understand what additional changes are going to occur to her “besides just getting a really huge belly.” Additionally, Beth relates to you that she is in her senior year of high school, is no longer involved with the baby’s father, and lives at home with her mother and 12-year-old brother. (Learning Objectives 2 and 4) a. Explain to Beth (in terms she can understand) what general body adaptations she will experience throughout the remainder of her pregnancy. Throughout pregnancy, she will experience bodily changes such as increased size of breast, stretch marks over the abdomen, increased blood circulation to the genitalia, absence of menstruation, intermittent nausea and vomiting, increased frequency of urination, weight gain, possible heartburn/indigestion, swollen feet and ankles, tiredness and pelvic pain/discomfort. b. What psychosocial adaptations may Beth experience as a result of being a teenage, single mother living at home? The psychosocial adaptations Beth may experience are dramatic body alteration, change in her social life, she may be afraid of giving birth and afraid of having pain during delivery. May have fears of raising the baby alone without the father.

Case Studies, Chapter 12, Nursing Management During Pregnancy 1. Nancy, age 38, and her husband, Dan, age 37, arrive at a midwife clinic for an initial prenatal visit. They have been married for 10 years and trying to have a child for 3 years. Nancy completes the initial paperwork and the nurse notes the following obstetrical history: G3, T0, P0, A2, L0. Nancy is approximately 8 weeks pregnant. (Learning Objectives 1, 3, and 4) a. What questions in the history are the highest priority for the nurse to ask, given Nancy’s obstetrical history? The nurse would seek further information about the documented abortions in Nancy’s obstetrical history. Information to gather would include the year/date of abortion, if the abortions were spontaneous (miscarriage) or induced, and weeks of gestation at the time of the abortion. Why is this history important? This history is important so that any areas such as health problems, lifestyle habits, or social concerns that might unfavorably affect pregnancy are identified. If the abortions were spontaneous, the nurse could ask about any related tests or diagnoses. The nurse would then be able to provide honest, supportive information and provide the health care provider with all data gathered during the history process to see if Nancy will be considered as a high-risk pregnancy. b. What initial prenatal screening and testing would the nurse anticipate at this visit? The nurse would plan to do a complete head-to-toe physical examination, including height, weight, and blood pressure. In addition, the nurse would plan for a pelvic examination. The pelvic examination would provide the health care provider with more information on the presumptive and probable signs of pregnancy. The nurse would plan to complete a full history, including the woman’s reproductive history. Laboratory studies could include urinalysis, blood type and Rh, complete blood cell count, rubella titer, hepatitis B, HIV testing, VDRL, RPR testing to test for syphilis, STD screening, and cervical smears. Why? These tests and screenings would be needed to provide a total picture of Nancy’s health and would assist in planning for the pregnancy. c. What prenatal screening and testing would the nurse anticipate for Nancy in the future related to her age? Due to Nancy’s age being 38 years old, she is considered to be of advanced maternal age and is in a high-risk category for pregnancy complications. Tests for Nancy could include ultrasonography, alpha-fetoprotein analysis (AFP levels), triple marker screen, amniocentesis, nonstress test, and biophysical profile. Why? Because when a pregnancy is identified as high risk, further antepartum testing is often completed to promote positive maternal, fetal, and neonatal outcomes. 2. Carla is 36 weeks pregnant with her first child. She is in the office for her regular prenatal checkup. This visit she shares incidences of increasing heartburn, low back pain, constipation, and difficulty sleeping at night. Carla would like to know what she can do to get relief from these symptoms. (Learning Objectives 5 and 6) a. Describe the nursing management for Carla’s reports. For the heartburn, review her dietary intake, have her limit gas-producing foods, fatty foods, and eat small frequent meals. Remain sitting for 1–3 hours after a meal. Avoid foods that aggravate the heartburn. For the backache, have her keep head and shoulders erect, avoid lifting heavy objects, use foot supports and pillows behind back, and sleep with pillows between knees. For the constipation, have her eat fresh fruit, raw vegetables, whole grain cereals and breads daily along with increase walking as tolerated, drinking 6–8 glasses of water per day, and drinking warm fluids. For sleep have her stay on a regular schedule. Take time to relax and unwind before bed. Try reducing the lighting in the bedroom and make the room temperature cooler. Avoid caffeine and limit fluid intake before bedtime. b. Now that Carla is nearing the end of her pregnancy, she has many questions regarding what to include as she starts preparing her birth plan. What information does Carla need to effectively plan for the birth of her baby? The information Carla needs to effectively plan for the birth of her baby are perinatal education, childbirth education, Lamaze psych prophylactic

method which focuses on breathing and relaxation techniques, Bradley partner-coached childbirth method which focuses on exercises and slow, controlled abdominal breathing, Dick-Read natural childbirth method which focuses on fear reduction via knowledge and abdominal breathing techniques. Information on feeding choices disadvantages and advantages for breast-feeding and bottle-feeding. Teaching and final preparation for labor and birth.

Case Studies, Chapter 13, Labor and Birth Process 1. Emily, age 32, has an obstetrical history of G1, T0, P0, A0, L0. Emily’s week of gestation is 39.1. Emily telephones the health care provider’s office and tells the nurse she believes she is in labor. Based on her assessment, the nurse advises her to have her husband bring her to the labor and birth unit. Emily arrives and is admitted. She is talkative and excited about being in labor and describes her contractions and discomfort as mild. The following are the assessment findings of the examining nurse: Maternal vital signs are stable. Fetal heart tones with the external fetal monitor are reassuring. Vaginal exam indicates the cervix is 3 cm dilated, 40% effaced, membranes intact with the presenting part engaged. Ten minutes after the vaginal exam by the nurse, Emily says, “I think I just wet my pants.” (Learning Objectives 2, 6, 7, and 8) a. What questions might the nurse have asked Emily to determine that she may be in true labor? Some questions the nurse could have asked Emily to see if it is true labor are: How far apart are her contractions? Frequency? Contraction strength and discomfort? Do the contractions increase or decrease with movement? Is she having any lower back pain? Does she have any bloody vaginal discharge/vaginal discharge? What prenatal history information should the nurse have obtained during the telephone call? Prenatal history information the nurse should have obtained during the telephone call are how many weeks pregnant is Emily, any previous preterm birth, history of miscarriages and any history of uterine abnormalities. b. Explain the meaning of the nurse’s assessment findings. The meaning of the nurse’s findings indicate Emily is in the first stage of labor in the latent phase. Identify the stage and phase of labor, listing the physiologic and psychological changes during this stage. First stage is from 0-10 cm dilation consists of three phases. Emily is in the latent phase which cervical dilation is from 0-3 cm, cervical effacement is from 0% to 40%, with frequent contractions every 5-10 min, contraction duration 30-45 sec that are mild. Vitals are stable and FHT are reassuring meaning the fetus is not in any distress. Having the mother walking around if she can to help move labor along. Since the mother and baby are both stable, she can participate in walking activities. The physiologic and psychological changes during this stage are back pain/ache constant with or without each contraction, increased heart rate, cardiac output, blood pressure, respiratory rate and oxygen consumption during contractions, menstrual-like cramping, increased white blood cell count, lower abdominal pressure, bloody show, energy burst, water breaks, cervical changes and effacement, fundal dominance can be noted, urge to have a bowel movement and micturition, decreased gastric motility and food absorption, decreased gastric emptying and gastric pH, slight temperature elevation, increased BMR and decreased blood glucose levels. Psychological changes are fear, anxiety, pain, emotional disturbances and wanting to have family members or spouse to be with them. What positions and activities would be appropriate for Emily based on the assessment data? Why? Positions and activities that would be appropriate for Emily based on the assessment data are having Emily walking around if she can to help move labor along. Since Emily and baby are both stable, she can participate in walking activities. c. Describe the nursing interventions that would be appropriate for the nurse to implement based on Emily’s statement that “I think I just wet my pants.” The nursing interventions that would be appropriate for the nurse to implement based on Emily’s statement would be to examine the cervix to see if the membranes did in fact rupture, if so, monitor the fetal heart rate for abrupt deceleration which could indicate fetal distress. Assess the fluid, it should be watery, clear and

pale to straw yellow in color with no foul odor and the volume should be between 500 ml to 1200 ml. Also test the fluid using nitrazine paper to confirm if it’s amniotic fluid and not urine when the paper turns deep blue in color. 2. Diane, age 22, has been in labor for 8 hours. Her cervical exam reveals she is 3 cm, 30% effaced and, –1 station. Diane has been feeling most of her pain in her lower back. (Learning Objectives 3, 4, and 5) a. Given your understanding of the five Ps and the cardinal movements of labor, discuss why Diane is having back labor and why her progress is slow. The reason why Diane is having back labor is because out of the 5Ps, it is the Passenger that is the cause of poor labor progress. This is the malposition of the fetus. It is likely in the occiput posterior position which is a head-down position of the baby facing Diane’s abdomen resulting in poor cervical dilation and back pain from applying pressure on her sacrum. b. What strategies may the nurse implement to assist Diane in progressing in her labor? The strategies that the nurse may implement to assist Diane in progressing in her labor are: Telling her to squat, ask her to sit on a birth ball, conduct an abdominal lift to try to change the position of the baby, Employing the Miles circuit technique, ask her to balance herself on hands and knees on the bed to adjust the fetal position, help her with breathing and relaxation techniques and apply some sacral pressure to relieve Diane’s pain if she’s experiencing pain.

Case Studies, Chapter 14, Nursing Management During Labor and Birth 1. Desiree, a 28-year-old G2P1, is admitted to the labor and birth unit. Her birth plan indicates that she is planning natural childbirth without pharmacologic interventions. She has attended childbirth education classes. Desiree is considered low risk based on her personal and family health history and physical exam. Her pregnancy has progressed without complications. She is approximately 38 weeks pregnant. Vaginal assessment reveals cervical dilation at 10 cm, 100% effaced, and +1 station. Position of the fetus is LOA. The external fetal monitor indicates a reassuring fetal heart rate at 130 bpm. Maternal status is stable. (Learning Objectives 1, 2, 5, and 8) a. Based on the vaginal assessment, identify the stage of labor and appropriate nursing interventions for this stage of labor. Based on the vaginal assessment, Desiree is in the second stage of labor where her cervix is completely dilated to the delivery of the infant and in the transition phase which starts from 7 cm to 10 cm dilation. The appropriate nursing interventions for this stage of labor are: Provide privacy, monitor V/S of mother and baby, assist mom in positioning to help with pushing, encourage rest between contractions, provide comfort measures such as cold compress, ice chips, ointment for chapped lips, encourage voiding every 1-2 hours, provide peri-care if patient has a bowel movement upon pushing and prepare mother for an episiotomy if needed. b. Explain how the nurse determined that the external fetal monitor would be appropriate for Desiree. The nurse was able to determine that external fetal monitoring would be appropriate for Desiree because the external fetal monitor is used on all stable patients giving birth and for only if the fetal heart rate is reassuring which in this case the fetal heart rate is reassuring and Desiree is in stable condition. What factors would necessitate a change to internal fetal monitoring during labor? Factors that would necessitate a change to internal fetal monitoring during labor would be rupturing of the membranes, non-reassuring fetal heart rates, if Desiree has gestational diabetes, hypertension or post-date gestation or prolonged labor that would cause abnormalities for the fetus such as fetal distress requiring need for the internal fetal monitoring. c. Desiree says, “I’m not sure I can cope with the pain much longer.” How would you respond, considering her birth plan, stage of labor, and assessment data? Considering her birth plan, stage of labor, and assessment data I would remind Desiree about her birth plan that she is planning for a birth without pharmacological intervention and inform her that the pain of delivery will be bearable

and short term for her because she has already achieved full dilation. I would also have her continue focusing on her breathing and encourage her to keep pushing. 2. Emily, a 26-year-old G3P2, has been in labor for 5 hours and is 7 cm, 90% effaced, and +2 station. She has external fetal monitoring in place, which reveals a baseline fetal heart rate of 120 bpm, minimal variability, and occasional variable decelerations. Suddenly, as a contraction is beginning to subside, the fetal heart rate drops to a low of 80 bpm and has a slow return to the baseline 1 minute after the contraction has ended. (Learning Objectives 3 and 4) a. What is happening to Emily’s baby at this point in time? What does this mean? Late deceleration is occurring which is putting Emily’s baby in fetal distress causing experiences of birth asphyxia (oxygen deprivation). This means this may include changes in the baby’s heart rate seen on a fetal heart rate monitor, decreased fetal movement and or meconium in the amniotic fluid. b. What role do you, as the nurse, play regarding fetal assessment and what interventions do you need to implement/recommend at this point in time? Nurse’s role is to assess that the fetal heart rate patterns reflects adequate fetal oxygenation and must distinguish between patterns indicating mild to severe fetal hypoxemia or hypoxia. Assist Emily in changing position, administer oxygen, ensure Emily is well hydrated, continue to monitor her contractions, watch for meconium stains in the amniotic fluid, obtain an IV access if needed and notify Emily’s provider.

Case Studies, Chapter 15, Postpartum Adaptations 1. You are caring for Linda, who has just delivered her first baby. You are responsible for assessing Linda’s condition during recovery and for doing patient teaching when the opportunity arises. (Learning Objectives 1, 2, and 6) a. While she is recovering, you keep checking her fundal height. Linda asks you how her uterus will go back to the way it was before she had the baby. How would you explain this physiologic process? What could impede the process? Your uterus will return to its normal size through a process known as involution. Involution has three retrogressive processes: 1. Contraction of the muscle fibers to reduce those previously stretched during pregnancy, 2. Catabolism which reduces enlarged individual myo-metrical cells and 3. Regeneration of the uterine epithelium from the lower layer of the decidua after the upper layer has been sloughed off and shed during lochial discharge. The retrogressive may not occur due to retained placental fragments or infection. b. Linda wants to know how long she should expect to bleed. What would you tell her? I would tell Linda lochia is a heavy blood flow of mucus that starts after delivery and continues for up to 10 days. Light bleeding and spotting after pregnancy can continue for up to four to six weeks after delivery which can vary from person to person. c. The next day Linda appears very passive and you have overheard her telling everyone who will listen about her labor experience. What phase of adjustment is Linda going through? What other stages should she go through while adjusting to her new role? The phase of adjustment Linda is going through is the taking-in phase, this phase will last 2-3 days. Here primary concerns will be her own needs of sleep and ...