Case Study part 1 - L&D Case PDF

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Case Study Part 1 Scenario You are the charge nurse working in Labor and delivery at a local hospital. D. H. comes to the unit having contractions and feeling somewhat uncomfortable. You take her in to the triage room to provide privacy, have her change into a gown, and ask her 3 initial questions to determine your next course of action, that is, whether to do a vaginal exam or not continue or to ask her more questions.

1. What are your three initial questions and why would you ask them? - How many weeks gestation is she? – to determine if she could be feeling Braxton Hicks contractions or true - How are the contractions? Far apart? Lasting? Pain? – characteristics of the contractions will help determine if they are true or false; if they are regular or irregular, does the pain go away with walking as they do in false - Are you having any vaginal discharge? – to determine if her water has broken or if she is having any bleeding 2. D. H. has contractions 2 to 3 minutes apart that last for 45 seconds. It is her third pregnancy (g3p2). Her bag of water is intact. You determine it is appropriate to ask her more questions before doing the vaginal exam. What information do you need? - Did you have any complications with your previous deliveries? Where they vaginal or C-section deliveries? Do you have any allergies? Have you discussed pain medication with your doctor? Would you like anyone else in the room with you? 3. What assessment(s) should you make to gain further information from D. H.? - Assess position of the baby using Leopold’s maneuver to determine where to place the doppler, get a BL FHR & contraction pattern from the toco, assess maternal VS, pain assessment, temperature, Perform a vaginal exam to check for dilation, effacement, & station 4. You check her, and she is 80% effaced and 4 cm dilated. The FHR is 150 beats/min. and regular. She is admitted to labor and delivery. What should you do now as the nurse? - Assess contractions q30min, maternal VS every hour, & FHR q30min; encourage the women to void so a full bladder won’t interfere with fetal descent; provide comfort measures like, back rubs, cool cloth on forehead, assist with position changes; give ice chips for dry mouth/lips 5. List the stages of labor and tell which stage D. H. is in, and why you put her in this stage. - First stage with 3 phases: Latent/Early, Active, Transition; Second stage, Third Stage, & Fourth stage - D.H. is in the first stage in the active phase because in this phase the cervix dilates 4-7 cm, has contractions 2-5 min apart, lasting 40-60 sec and she is dilated 4 cm with contractions 2-3 min apart, lasting 45 sec. 6. Decelerations occur in an early, variable, or late pattern. What is the significance of each and what nursing care should you provide for each? - Early Decelerations are due to head compression during uterine contractions. No nursing care is needed. - Variable Decelerations are due to cord compression. Nursing care is change maternal position change, stop Pitocin if being used, vaginal exam to assess for prolapsed cord, give O2, notify the physician

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Late Decelerations are due to uteroplacental insufficiency. Nursing care is maternal position change, increase administration of IV fluids, O2 via face mask, stop Pitocin if being used, notify the physician 7. D. H. delivers a male infant vaginally with in an episiotomy. What is the immediate care that should be provided to the newborn? - Place the newborn on the mothers chest so skin-to-skin contact is started, maintain respirations by placing baby in Trendelenburg position for easy drainage of mucus & suction with a bulb syringe, dry newborn and apply warm, soft blankets & remove wet blankets, apply stocking cap on baby’s head; evaluate newborn using the Apgar scoring system for HR, respirations, muscle tone, reflex response, & skin color; assess temperature 8. The episiotomy and repaired and the placenta is delivered. What are the signs that the placenta has released from the uterine wall? - Signs of placental separation are uterus rises in the abdomen, umbilical cord lengthens, a sudden trickle/spurt of blood, uterus changes to a globular shape 9. What assessments should the nurse provide post-delivery? - The nurse should determine the relationship of the fundus to the umbilicus, assess the firmness of fundus, assess the amount/character of blood expelled, assess lochia for character/amount/odor & presence of clots, assess the episiotomy in sims’ position for redness/edema/ecchymosis/discharge/approximation q15min during 1 st hour after birth, assess for a distended bladder, implement method to aid in voiding – help her get out of bed to void, encourage relaxation & deep breaths, or catheterize if necessary, monitor urine output, assess for hemorrhoids around the anus, assess for thrombophlebitis by evaluating for a + Homan’s sign, assess emotional status for depression, support systems, low self-esteem; assess vital signs, assess pain level from the episiotomy & implement pain relief measures – ice pack...