Maternal Newborn Scenarios PDF

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Maternal Newborn Scenarios

Clara Guidry Room 302 Clara Guidry, 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.

You responded correctly to 6 out of 6 evaluations: Category

Your response

Explanation

Category Fall Risk Health Change Pain Level Psychological Needs Sensorium

Your response Increased acuity Increased acuity Normal acuity Increased acuity Increased acuity

Explanation Status assessment reports patient is still numb from epidural and unable to mo Status assessment reports pooling of blood with large clots. Status assessment does not indicate report of pain and patient is still under ef Status assessment reports pooling of blood, patient reports feeling light-heade patient unable to sense need to void. Status assessment reports patient reporting feeling light-headed and still num

Clara Guidry 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 lightheaded. Her husband is at her bedside.

You correctly diagnosed 10 out of 13 options: Physiological

Description Acute Pain Bleeding

Deficient fluid volume related to uterine atony/postpartum hemorrhage Impaired mobility Impaired patterns of elimination

Ineffective tissue perfusion related to hypovolemia Infection

Your Response E False Status assessment reports lingering nu True Status assessment reports blood poolin secondary to uterine atony because of use and large infant. True Status assessment reports blood poolin

True True

True False

Status assessment reports effects conti Status assessment reports continued nu having been removed previously; patie contribute to uterine atony and hemorr Status assessment reports blood poolin and light-headed and appears pale Status assessment reports no indication

Your Response E False Status assessment reports no indication

Description Nausea Safety

Description Deficient knowledge

Your Response Explan True Status assessment reports patient reports feeling w from epidural; unaware of potential for uterine aton require education and support. True Status assessment reports patient is still numb from

Disturbed sensory perception Fall, risk for self and risk True for dropping baby False Impaired maternal newborn bonding False Peripheral Neurovascular Dysfunction

Status assessment reports lingering numbness from feeling light-headed Status Assessment reports mother is currently holdi Status assessment reports no indication of increase

Clara Guidry Scenario 1 You enter the patient’s room. After washing and gloving hands, you introduce yourself and verify identities of the patient, Mrs. Clara Guidry and the baby. Assessment findings: Blood pooling under buttocks with several large clots; fundus boggy and slightly deviated to the right, 3 cm. above umbilicus; Vital signs: BP 90/60, P 110, R. 20, SAO2 98%, skin color pale, patient alert and oriented; unable to move legs, holding and breastfeeding baby. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

You correctly ordered 1 out of 5 actions: Your Correct order order Step 1 1 Assist mother to unlatch infant from breast and place infant in crib or hand to the husband. 3 2 Massage uterine fundus. 2

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Patient is light-headed and h mother’s arms. Infant safety

Massaging the fundus until f vessels at the placental site Call for help using emergency call system. Postpartum hemorrhage is t requiring a rapid, team appr Set oxytocin rate to Bolus on IV pump as Rapid infusion of oxytocin ca ordered by healthcare provider. clamping off blood vessels f Assess bladder status and need to A full bladder displaces the atony. Her uterus is slightly perform straight catheter. for catheterization.

Clara Guidry Scenario 2 Assessment reveals a very distended bladder, displacing fundus 3 cm above the umbilicus and displaced to the patient’s right patient unable to void due to lingering effects of epidural. A physician order is received to insert an indwelling urinary catheter. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

You correctly ordered 0 out of 5 actions: Your Corre orde ct r order Step 4 1 Educate patient regarding indwelling urinary catheter placement, Wash hands.

Explanation Education allows for planning and implementation of patient care; washing hands prior to indwelling urinary catheter placement prevents nosocomial infection during invasive procedure and is the

Your Corre orde ct r order 5

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Explanation first step. Insert indwelling Insertion of Indwelling urinary urinary catheter catheter is done according to and connect to established protocols, under collection bag, sterile technique and is the secure to patient’s second step. The patient is thigh. unable to void, and a full bladder is a common cause of uterine atony and early postpartum hemorrhage. Measure urine Assesses adequate emptying return in collection of bladder; emptying bladder bag; Reassess returns uterus to normal and uterine tone, position and facilitates normal response to contraction of the uterus. massage, level in relation to umbilicus, and position in abdomen. Reassess vaginal A firmly contracted uterus bleeding and clamps off blood vessels at presence for clots; the placental site, preventing change underpads uterine atony and excessive as needed. bleeding, changing underpads for patient comfort and prevention of infection. Wash hands, Prevents spread of infection; document findings accurate documentation is to and completion of be performed after patient procedure. care is performed, NEVER BEFORE!

Clara Guidry Scenario 3 Following indwelling urinary catheter placement, and upon reassessment, bladder is non-distended, fundus is 1 cm. below the umbilicus, beginning to firm up with massage, but bleeding remains excessive with large clots

continuing. Patient remains pale and is anxious. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

You correctly ordered 1 out of 5 actions: Your Correct order order 5 1 Reassess vital signs. 2

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Indicates physiolo meds, BP must b Set plain Lactated Ringers to Bolus rate on IV pump. Next the nurse m hypovolemia and Administer Methergine 0.2 mg IM per healthcare Methergine cause provider order. clamping off bloo excessive bleedin Assist healthcare provider with exam to assess for Unrecognized ce cervical or vaginal lacerations/hematoma or retained stage labor and l placental pieces. bleeding, especia Anticipate laboratory studies: CBC, blood typing and Laboratory studie crossmatch, coagulation studies. which can cause

Clara Guidry Scenario 4 Further assessment: no cervical or vaginal lacerations; coagulation studies are WNL, BP 84/56, P 114, R 24, SAO2 94%, fundus firms with massage but otherwise boggy, excessive bright red vaginal bleeding with large clots. Patient complains of feeling more light-headed and is paler. Other registered nurses are caring for the newborn and providing education and support to the husband. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

You correctly ordered 3 out of 5 actions: Your Correct order order Step 1 1 Administer Oxygen via nonrebreather face mask Hypovolemia from blo at 10-12L/min. circulating oxygen leve priority. 2 2 Assist healthcare provider with administration of Causes a sustained firm

Your Correct order order

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Step misoprostol (Cytotec) 1000 mcg rectally.

Establish an additional IV line and anticipate additional crystalloids (Lactated Ringer’s), colloids (albumin), blood and blood products. Continue to closely monitor vital signs, uterine fundus tone/level and vaginal bleeding. Anticipate healthcare provider insertion of postpartum balloon and/or return to operating room.

vessels at the placenta medication may be giv line. Fluid resuscitation and volume and successfu hemorrhage. Indicates physiologic r uterotonic meds and p components. Balloon exerts inward resulting in a reduction the endometrium and

Clara Guidry Scenario 5 Further assessment: BP 106/64, P. 86, R 22, SAO2 97%, fundus firm, 2 cm below umbilicus, lochia moderate, no clots, patient is alert and oriented, less pale, but too tired to breastfeed baby. She expresses a concern about baby not being held or fed. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

You correctly ordered 0 out of 5 actions: Your Correct order order Step 4 1 Use therapeutic communication/active listening to assess patient’s concerns and interest in pumping for colostrum. 5

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Acti conc don Consult Lactation Consultant or provide education to patient and Prov assist with pumping. Discuss with patient’s partner for willingness/interest to feed Allo baby colostrum. pate Assist partner in feeding pumped colostrum and partner skin-to- Prom skin contact. Assess patient’s ability to hold infant and assist patient with Faci holding baby skin-to-skin after feeding for maternal-infant mat bonding.

Jenny Theriot Room 302 Jenny Theriot, 30 y/o G1P0 at 31 weeks’ gestation. She has had an uncomplicated pregnancy until this morning when she woke up with clear fluid leaking from her vagina. She denies having contractions but says she isn’t really sure what she is feeling. She presents to the Obstetrics Triage Unit, looking distraught and crying, and says she doesn’t understand what is going on.

You responded correctly to 5 out of 6 evaluations: Category Educational Needs Fall Risk Health change Pain level Physiological Needs Sensorium Needs

Your response Increased acuity Increased acuity Increased acuity Normal acuity Increased acuity Normal acuity

Explanation Status assessment reports leaking of fluid from vagina, possible contractions a and support for the client. Status assessment reports the client is pregnant; this changed her center of g Status assessment reports leaking of fluid from vagina and possible contractio Status assessment does not indicate report of pain. Status assessment reports leaking of fluid from vagina, possible contractions. Status assessment reports no indication of changes in sensorium.

Jenny Theriot 30 y/o G1P0 at 31 weeks’ gestation. She has had an uncomplicated pregnancy until this morning when she woke up with clear fluid leaking from her vagina. She denies having contractions but says she isn’t really sure

what she is feeling. She presents to the Obstetrics Triage Unit, looking distraught and crying, and says she doesn’t understand what is going on.

You correctly diagnosed 10 out of 10 options: Physiological

Description Acute Pain Anxiety Impaired mobility, risk for Impaired patterns of elimination Infection, Risk for Nausea Safety

Description Deficient knowledge Disturbed sensory perception Fall, risk for Risk for injury, maternal/fetal

Your Response Explan False Status assessment indicates unknown status of contr True Status assessment reports woman crying, stating she False No indication at this time False

Status report does not indicate impaired elimination.

True

Status assessment reports leaking of fluid from vagin membranes (SROM); risk for ascending infection and Status assessment reports no indication of nausea.

False

Your Response True False

Exp Status assessment reports woman crying, un to her. Status assessment reports normal sensory p

True True

Client is pregnant and is at risk for falls relate Status assessment reports possible SROM an

Jenny Theriot Scenario 1 You enter the patient’s room. After washing and gloving your hands, you identify yourself and the patient, Mrs. Jenny Theriot. You assist her to change into a gown and place her on a triage stretcher in semi-Fowler’s position. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

You correctly ordered 3 out of 5 actions: Your Correct order order Step 2 1 Establish therapeutic communication; review prenatal Establishes trus history with woman and events leading her to present patient care. to triage. 1 2 Assess vital signs, including temperature. Establishes bas increases risk o increases as a 3 3 Perform Leopold’s Maneuver. Identify position difficult at 31 w 4 4 Apply external tocodynamometer and fetal transducer Detects and re and palpate fundus to assess for contractions. intensity, detec fetal back. 5 5 Using a sterile gloved hand, test fluid leaking from Nitrazine paper vagina with Nitrazine paper. (acidic).

Jenny Theriot Scenario 2

Spontaneous rupture of membranes (SROM) confirmed by +Nitrazine test and collection of fluid with +Fern test. A Biophysical Profile (BPP) is performed to assess fetal status and amniotic fluid volume, which is found to be decreased. Amniotic fluid continues to leak from vagina. Orders are received to admit to Prenatal Unit and implement Prenatal Premature Rupture of Membranes (PPROM) protocol. An IV of 1000 ml D5W is started to ensure adequate hydration. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

You correctly ordered 2 out of 5 actions: Your Correct order order Step 1 1 Place bed in Trendelenburg position.

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Assists in relieving premature cervica continuing leaking Discuss plan of care with patient; answer questions Provision of clear care and can allay honestly, especially concerning SROM and implications for preterm labor and birth. Assess support systems available to woman. Assistance and ca stressful events. Apply sequential compression device (SCD) boots Prevents the form and connect to machine. Begin Intake and Output (I&O) chart and document Ensures adequate every shift.

Jenny Theriot Scenario 3

Mrs. Theriot continues on complete bedrest in Trendelenburg position. Upon entering her room she tells you that she “had a gush of fluid and feels like something came out of her vagina”. She also reports feeling hot and flushed and that she is not sure if her baby is moving as much as it was previously. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

You correctly ordered 1 out of 5 actions: Your Correct order order Step 4 1 Inspect perineum.

Possible umbilical cord prolapse with Patient states she “feels like someth prolapsed cord is the quickest asses Occult prolapse of umbilical cord cut potential fetal death. Significant cha hidden or occult prolapsed cord. Increasing temperature indicates inf

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Assess FHR for bradycardia.

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Assess vital signs, including temperature. Assess for contractions; palpate On-going vigilance for signs of prete detected by monitor or recognized b fundus. Indicative of infection or chrioamnio Assess for foul odor to amniotic fluid; perform pericare and provide fresh underpads.

Jenny Theriot Scenario 4 Four days later Mrs. Theriot remains on bedrest and continues to leak small amounts of amniotic fluid. Assessment: BP 110/70 mmHg, P. 78

beats/minute, R 20 breaths/minute, T. 99.4o F. Due to the potential for developing chorioamnionitis, her healthcare provider is increasingly concerned about possible pre-term delivery and writes new orders for her continuing care. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

You correctly ordered 2 out of 5 actions: Your Correct order order Step 4 1 Perform Non-Stress Test (NST) now and bi-weekly BPP and every shift; teach woman to do Daily Fetal Movement Counts (DFMCs). 2

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Reactive NST indicative of fetal fetal compromise. Biophysical P ultrasound to evaluate a babys and amniotic fluid level. The NS signs of fetal compromise Administer Betamethasone 12 mg IM for Stimulates fetal lung maturity b production or release of lung su two doses 24 hours apart. Administer a broad-spectrum antibiotic Treat infection, decrease inciden additional 24 hours to elapse af (e.g., ampicillin, erythromycin) and continue for 7 days. Request neonatologist to visit patient. Affords opportunity to discuss ca anxiety. Assess results of daily CBC. Increasing WBC indicative of inf

Jenny Theriot Scenario 5 Mrs. Theriot is weepy and says she is tired of being in bed and in the hospital. She is also having a hard time resting because of the multiple interruptions involved with her care. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

You correctly ordered 0 out of 5 actions: Your Correct order order Step 5 1 Encourage vocalization of fear and concerns. 3 2 Cluster nursing care activities as much as possible, such as medication administration, assessments, and vital signs. 4 3 Offer diversional activities: watching TV, reading, crossword puzzles, small needlecraft activities. Request family to bring articles from home to “decorate” hospital room. 2 4 Teach conscious relaxation and breathing techniques. 1

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Can he Promo interru Assist mobili “norm Non-ph and de Provide comfort measures such as back rubs, position changes, Decre and aromatherapy. feeling

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 ...