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Stephanie Gold, 19-year-old Caucasian female, G1 T0 P0 A0 L0, 32 weeks gestation. Uncomplicated pregnancy except for anemia treated with PO iron. States 3 times in last week has called on-call obstetrician about fatigue, body aches, mild nausea during the evening. The client reports, “I don’t feel well, I haven’t vomited, but nausea makes me not want to eat too much. I am drinking ok, just want to eat bland foods.” Rest and acetaminophen were recommended. Client is first-year nursing student and states several students have had a “GI bug”. States during day felt better and went to school all but one day. No fever. She stated: “Can’t be absent from nursing school!” No contractions, leaking of fluid or vaginal bleeding. Came in this morning (Saturday) due to pain by right rib cage. States this is new today. Boyfriend accompanies client.  Educational- increases acuity Fall risk-increased acuity HEalth change- increased acuity Pain level- increased acuity Psychological needs- increased acuity Sensorium- normal acuity   Clara Guidry, Patient is a 34 y/o G5P4 who gave birth to a 9lb. 3 oz male infant following a 12-hour elective cin induction of labor. She had an uncomplicated labor, epidural anesthesia and a rapid second stage, no episiotomy or perineal lacerations. Indwelling urinary catheter was removed prior to delivery. She is now one hour postpartum and is breastfeeding her baby. An IV of 1000 mL Lactated Ringers is infusing at KVO rate with an infusion of Lactated Ringers with oxytocin 20 Units infusing IVPB at 125 mL/hour. Upon entering her room, she tells you that she “feels wet”, and may have urinated on herself since she is still numb from the epidural and unable to move legs. Your assessment reveals blood pooling under buttocks onto the underpads with numerous large clots. She is anxious, appears pale, and complains of feeling light-headed. Her husband is at her bedside.   Educational- increased acuity Fall risk-increased acuity HEalth change- increased acuity Pain level- normal acuity Psychological needs- increased acuity Sensorium- increased acuity 

Physiological: Acute pain, bleeding, deficient fluid volume related to uterine atony, impaired mobility, infection Safety:Fall risk, impaired maternal newborn bonding, peripheral neurovascular dysfunction  Jenny Smith, 23-year-old, G2P1, estimated gestation age of 10 weeks with complaints of vaginal bleeding and abdominal cramping. No medical hx, allergic to sulfa drugs. Lab results showed a decreased serum HCG from previous result. No fetal movement seen by ultrasound and no fetal heart tones could be obtained. Pelvic exam revealed an open cervical os with blood noted. She states that her pain is abdominal cramping, rates it from a 4/10 to a 7/10 and is still having vaginal bleeding. She has pain medication prescribed q4h prn and received a dose about 1 hour ago with some relief. Her vitals are stable at 98.1o F., Heart rate 89 bpm, 18 breaths/minute, 132/68 mmHg, O2 Saturation 98% on room air. She’s currently NPO until the need for dilation and curettage is ruled out. She has an IV in her left forearm, no fluids infusing at this time. She verbalized understanding of the findings and is visibly upset. She expresses concern about her family dealing with the loss and how she will tell them. She has been speaking with the staff about loss and is receptive to education regarding the next steps.   Educational- increased acuity Fall risk-increased acuity HEalth change- increased acuity Pain level- increased acuity Psychological needs- increased acuity Sensorium- normal acuity  Jessica Wu, 35-year-old Asian female, G3 T2 P2 A0 L2, 35 weeks gestation. NKDA. Previous pregnancies uncomplicated but Cesarean births due to persistent breech position. Smoker x 15 years but states she “cut back to 3 cigarettes/day during her pregnancies.” Reports that she started smoking during college. States started having moderate amount of bright red bleeding about 0800. Came to the hospital after dropping the older children at school (5 and 7 years old). She has called her husband and he is meeting her at the hospital because he was already at work. It is now 0945. She is anxious about the bleeding. States she “never had anything like this with her other pregnancies!” Denies pain, contractions, or leaking of amniotic fluid.  Educational- increased acuity Fall risk-increased acuity

HEalth change- increased acuity Pain level- normal acuity Psychological needs- increased acuity Sensorium- normal acuity  Miranda Johnson, 32 y/o G3P2 at 39 weeks gestation. It has been 10 years since her last pregnancy. She was admitted to Labor & Delivery late last night in active labor. Upon admission, sterile vaginal exam (SVE) was 2 cm dilated, 80% effaced and -1 station (2/80/-1). She had small amount of bloody discharge, but membranes were intact. Contractions were every 3-4 mins., lasting 50-80 secs., with reassuring fetal heart rate (FHR). She rated her pain as 3 on 0-10 pain scale and stated most of the pain was in her back and vaginal area. Ms. Johnson was weighed on admission at 250 pounds, she reported that she is allergic to penicillin, and has mild scoliosis. On admission, Ms. Johnson admitted that she does not tolerate pain well and wants an epidural like she had with her previous pregnancies. Her significant other is in the room on the couch playing games on his IPAD, and frequently texting on his phone. At 0630, her water broke (SROM-spontaneous rupture of membranes) and fluid was clear. SVE is 4 cm dilated, 90% effaced, and 0 station (4/90/0) with contractions every 2-3 mins., lasting 40-70 secs., with reassuring FHR. Pain level is 7-8 out of 10, and she became increasingly irritable, short tempered, and requested an epidural. IV fluids, 1000 ml of Lactated Ringers were infused at 125ml/hr. per order. There are signed orders for an epidural PRN (as needed).    Educational- increased acuity Fall risk-increased acuity HEalth change- increased acuity Pain level- increased acuity Psychological needs- increased acuity Sensorium- normal acuity   Patient is a 34 y/o G5P4 who gave birth to a 9lb. 3 oz male infant following a 12-hour elective oxytocin induction of labor. She had an uncomplicated labor, epidural anesthesia and a rapid second stage, no episiotomy or perineal lacerations. Indwelling urinary catheter was removed prior to delivery. She is now one hour postpartum and is breastfeeding her baby. An IV of 1000 mL Lactated Ringers is infusing at KVO rate with an infusion of Lactated Ringers with oxytocin 20 Units infusing IVPB at 125 mL/hour.

Upon entering her room, she tells you that she “feels wet”, and may have urinated on herself since she is still numb from the epidural and unable to move legs. Your assessment reveals blood pooling under buttocks onto the underpads with numerous large clots. She is anxious, appears pale, and complains of feeling light-headed. Her husband is at her bedside.  Physiological- acute pain, deficient fluid, impaired mobility,   Jessica Wu 35-year-old Asian female, G3 T2 P2 A0 L2, 35 weeks gestation. NKDA. Previous pregnancies uncomplicated but Cesarean births due to persistent breech position. Smoker x 15 years but states she “cut back to 3 cigarettes/day during her pregnancies.” Reports that she started smoking during college. States started having moderate amount of bright red bleeding about 0800. Came to the hospital after dropping the older children at school (5 and 7 years old). She has called her husband and he is meeting her at the hospital because he was already at work. It is now 0945. She is anxious about the bleeding. States she “never had anything like this with her other pregnancies!” Denies pain, contractions, or leaking of amniotic fluid.  Physiological- Acute pain, deficient fluid volume, injury risk for fetal, fall risk, anxiety, fear  Stephanie Gold 19-year-old Caucasian female, G1 T0 P0 A0 L0, 32 weeks gestation. Uncomplicated pregnancy except for anemia treated with PO iron. States 3 times in last week has called on-call obstetrician about fatigue, body aches, mild nausea during the evening. The client reports, “I don’t feel well, I haven’t vomited, but nausea makes me not want to eat too much. I am drinking ok, just want to eat bland foods.” Rest and acetaminophen were recommended. Client is first-year nursing student and states several students have had a “GI bug”. States during day felt better and went to school all but one day. No fever. She stated: “Can’t be absent from nursing school!” No contractions, leaking of fluid or vaginal bleeding. Came in this morning (Saturday) due to pain by right rib cage. States this is new today. Boyfriend accompanies client.   Imbalance fluid volume, injury risk for fetal, injury risk for maternal, nausea, fall risk, anxiety, disabled family coping 

 23-year-old, G2P1, estimated gestation age of 10 weeks with complaints of vaginal bleeding and abdominal cramping. No medical hx, allergic to sulfa drugs. Lab results showed a decreased serum HCG from previous result. No fetal movement seen by ultrasound and no fetal heart tones could be obtained. Pelvic exam revealed an open cervical os with blood noted. She states that her pain is abdominal cramping, rates it from a 4/10 to a 7/10 and is still having vaginal bleeding. She has pain medication prescribed q4h prn and received a dose about 1 hour ago with some relief. Her vitals are stable at 98.1o F., Heart rate 89 bpm, 18 breaths/minute, 132/68 mmHg, O2 Saturation 98% on room air. She’s currently NPO until the need for dilation and curettage is ruled out. She has an IV in her left forearm, no fluids infusing at this time. She verbalized understanding of the findings and is visibly upset. She expresses concern about her family dealing with the loss and how she will tell them. She has been speaking with the staff about loss and is receptive to education regarding the next steps.  Acute pain, altered family process, bleeding decreased cardiac output, ineffective airway clearance, ineffective coping, suicidal ideations, fall risk, imparied mobility  32 y/o G3P2 at 39 weeks gestation. It has been 10 years since her last pregnancy. She was admitted to Labor & Delivery late last night in active labor. Upon admission, sterile vaginal exam (SVE) was 2 cm dilated, 80% effaced and -1 station (2/80/-1). She had small amount of bloody discharge, but membranes were intact. Contractions were every 3-4 mins., lasting 50-80 secs., with reassuring fetal heart rate (FHR). She rated her pain as 3 on 0-10 pain scale and stated most of the pain was in her back and vaginal area. Ms. Johnson was weighed on admission at 250 pounds, she reported that she is allergic to penicillin, and has mild scoliosis. On admission, Ms. Johnson admitted that she does not tolerate pain well and wants an epidural like she had with her previous pregnancies. Her significant other is in the room on the couch playing games on his IPAD, and frequently texting on his phone. At 0630, her water broke (SROM-spontaneous rupture of membranes) and fluid was clear. SVE is 4 cm dilated, 90% effaced, and 0 station (4/90/0) with contractions every 2-3 mins., lasting 40-70 secs., with reassuring FHR. Pain level is 7-8 out of 10, and she became increasingly irritable, short tempered, and requested an epidural. IV fluids, 1000 ml of Lactated Ringers were infused at 125ml/hr. per order. There are signed orders for an epidural PRN (as needed).  Risk for imparied urinary elimination, risk for maternal injury, deficient knowledge, fall risk for 

After obtaining report as above the nurse also learns that Jessica is O-, Rubella immune, and was Group B Strep negative with previous pregnancies. Her hemoglobin level was 11.5 g/dL with a hematocrit of 34.5% at 28 weeks gestation. All of the other lab findings are normal. The nurse enters Jessica’s room to begin the initial shift assessment. Her husband, Dan, is now at her side. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:    1.)Wash hands and introduce self to the client and her husband. 2.) obtain her vitals 3.) educate the client 4.) apply gloves 5.) offer peri care

  The nurse completes an initial assessment. T 36.6 C, 97.8 F; P 96 beats/minute, regular; R 20 breaths/minute, regular; BP 128/84 mmHg; FHR 125, moderate variability, 2 accelerations to 145 in 20 minutes. No contractions on EFM. Normal resting tone. Abdomen soft, nontender. Fundal height measures 37 cm. Urine negative for protein on dipstick. States that the current pad is the first pad applied at home. 15 cm saturation bright red blood on pad, no clots. Nonpitting pedal edema. DTR +2 bilaterally. The healthcare provider is notified of the assessment and the following orders are given. The client and her husband are educated about each of the orders. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:  1.)Assist client to assume side lying position. 2.) CBC, chem panel, type and screen 3.) continuous efm. Vital signs q15min 4.) IV 18

gauge lactated 5.) Rh immunoglobulin 300 mcg 6.) IM betamethasone 12 mg  Ultrasound shows a partial posterior placenta previa. Biophysical profile 10/10 and normal Amniotic fluid volume. Chem Panel normal. Hgb 10 g/dL and HCT 30%. Platelets 160,000. The nurse admits the client for expectant management of placenta previa. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: Not all interventions should be completed   1.)Assist client to lateral positioning 2.) maintain Iand O 3.) bring extra pillows 4.) Bring bed pan 5.) educate client and husband 6.) prepare to assist with a vaginal exam  The client’s condition stabilized and bleeding stops. After 48 hours, she is discharged to home with the following instructions. The nurse selects instructions as part of the nursing actions. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: 1.)If bleeding resumes return to hospital 2.)keep all appointments 3.) Ensure the client lives within a short distance 4.) discuss willingness to comply 5.) discuss diversionary activities and provide resources  Two weeks later, Jessica returns to the hospital. She is now 37 weeks gestation. She says, “I woke up in a puddle of blood this morning. I wasn’t doing anything! I’m not having any pain or contractions.” Her husband says he called her doctor and the doctor is meeting them at the

hospital. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: 1.)Call for assistance, 2.) obtain vitals 3.) administer oxygen via non rebreather 4.) insert 18 gauge IV with normal saline 5.) insert indwelling catheter  Renee Wilson scenario 1 1.)Discuss c-section, allow woman to verbalize feelings, praise woman and husband for efforts, encourage frequent positions, suggest changing to a more complex breathing techniques Scenario 2 Assist woman to bed, using sterile glove test fluid, asses color, asses contraction, reassess maternal vital signs  Scenario 3 Reassess maternal and fetal status, encourage her to void, assist with peri care, teach husband how to apply counter pressure, continue to provide comfort  Scenario 4 Asses fhr before removing transducer, insert foley cath, apply sequential compression device, perform lap needle and instrument count, perform time out  Scenario 5 Assist in drying, perform apgar, asses vital signs, place matching ID bands, place infant skin to skin  After obtaining report, the nurse looks in the computer for Jennifer’s prenatal record and lab reports. She is A+, Rubella immune, and GBS

negative with previous pregnancies. Her hemoglobin level was 11 g/dL with a hematocrit of 33% at 28 weeks gestation. All the other lab findings are normal. The nurse enters Jennifer’s room to begin the initial shift assessment. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: 1.)Wash hands intro, obtain her vitals, educate the client, apply gloves, ask the client not to get up Scenario 3 Maintain bedrest, bring extra pillows, bring scale, bring bedpam, educate client and significant other, conduct a vaginal exam   Cindy mason Scenario 1 Review prenatal history, obtain maternal vitals, perform leopolds, apply fetal transducer, perform sterile vaginal exam  Scenario 4 Assist women to birthing bed, request assistance for room, ensure neonatal resus equip is avail, encourage woman to push, encourage deep breaths  Scenario 5 PErform apgar, place infant skin to skin, reasses maternal vitals, reassess uterine fundus, reassess lochia  Aminiah Hussain Education needs- increased acuity Fall risk- increased acuity Health change- increased acuity Pain level- normal acuity Psychological needs- increased acuity

Sensorium- normal acuity

 Aminiah Hussain Physiological- Acute pain, chronic pain, fall risk, injury risk for fetal, injury risk for maternal, anxiety, deficient knowledge, disbaled family coping, fear, spiritual distress  Scenario 1 Wash hands, ask client and husband what they prefer to be called, ask if there is need for an interpreter, ask for permission, educate client about the status of fetal  Scenario 2 Who do you want to be in with you in labor, what can your labor support person do to help you be most comfortable, what actions are important for you and your fam, what do you expect from the nurses, how will other members of the family participate Scenario 3 1.)Provide written 2.)Female health care providers 3.)After birth 4.)Assess 1min 5.)Allow mother to rub a soft date  Scenario 4 Assess fetal status, asses contraction, initiate primary IV, Oxytocin 30 units, assess BP  Scenario 5

1.)Discontinue the oxytocin 2.)Reposition the client 3.)Administer oxygen 4.)Administer IV 5.)Administer terbutaline Jamie Maria Sanchez Room 304 20 year old female, G1 P1 L1, 39 weeks gestation. Pregnancy uncomplicated Educational: Increased Fall Risk: Increased Health changes: Increased Pain Level: Increased Psychological Needs: Increased Sensorium: Normal SAFETY Fall risk: TRUE Injury, risk for maternal: FALSE PHYSIOLOGICAL Acute Pain: TRUE Chronic Pain: FALSE Ineffective breastfeeding, risk for: TRUE Infection, risk for: TRUE LOVE AND BELONGING Anxiety: FALSE Deficient knowledge: TRUE Readiness for enhanced parenting: TRUE

SCENARIO 1 1. Wash hands and introduce self to the client and her husband. 2. Ask the client and her husband what they prefer to be called.

SCENARIO 2 1. Reassure Maria that engorgement is a common and temporary condition. 2. Instruct Maria to breastfeed Juan every 2-3 hrs.

SCENARIO 3 1. “Position your baby skin to skin w/ you for a few minutes”. 2. “Hold your baby like a football”

SCENARIO 4

1. “Juan should have 6-8 wet diapers of light yellow urine every24 hrs. Its a good idea to write them down to help you remember”. 2. “By the 4th day Juan should have at least 3 yellow green stools and they should be looser than the dark green stools he had on the first few days”.

SCENARIO 5 1. “Maria take 3 deep breaths in and exhale slowly while i count to 3”. 2. “An appointment can be made for first thing in the morning so you don't have to wait in the waiting room at the lactation clinic”.  

Jenny Smith Room 305 23 year old female, G2P1, estimated gestation age of 10 weeks w/ complaints of vaginal bleeding and abdominal cramping. EDUCATIONAL: Increased FALL RISK: Increased HEALTH CHANGE: Increased PAIN: Increased PHYSIOLOGICAL: Increased SENSORIUM: Normal PHYSIOLOGICAL Acute pain: TRUE Altered family process: TRUE Anxiety: TRUE Bleeding:TRUE Decreased cardiac output:FALSE Depression, risk for: FALSE Grieving: TRUE Ineffective airway clearance: FALSE Ineffective coping: FALSE Infection, risk for: TRUE Nausea: FALSE Suicidal: FALSE SAFETY Fall, risk:TRUE...