Obstetrics Triage definitions PDF

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Concepts of Nursing III...

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Phase One: Obstetrics Triage definitions Select the term from drop-down that matches the definition below. "A condition in pregnancy associated with preeclampsia whereby the pregnant patient experiences a critical hemolysis, elevated liver enzymes and low platelet count." The term you selected, "HELLP Syndrome", was CORRECT. "An inpatient procedure whereby contractions of the uterus and/or cervical dilation are initiated in the absence of natural labor by artificial rupture of amniotic membranes (AROM), and/or cervical ripening agents and/or IV oxytocin." The term you selected, "Induction of Labor", was CORRECT. "Amniotic fluid that contains products of the fetus’s first bowel movement in utero. The presence of this in the fluid is not harmful to the fetus in utero; however, aspiration of the fluid by the infant at or after delivery may result in respiratory complications, infection and/or other serious complications. Careful assessment of the time, amount, color and odor of the amniotic fluid is of high priority, prior to birth." The term you selected, "Meconium Staining", was CORRECT. "A condition in which the neck of the lower uterine segment begins to open, or dilate, in the second trimester of pregnancy." The term you selected, "Incompetent Cervix", was CORRECT. "A pregnancy-related complication of unknown cause that is characterized by high blood pressure (when pre-pregnancy BP’s were normal) and signs of damage to other organ systems such as the kidneys, leading to a condition known as proteinuria. Usually begins after 20 weeks of pregnancy and if left untreated can lead to serious, even fatal, complications for the mother and the baby." The term you selected, "Preeclampsia", was CORRECT. Jessica Sims

A G2P1 at 32 weeks gestation presents to the emergency department with no history of prenatal care. She has sought out medical care for complaints of a migraine-like headache that has persisted for the last 24 hours. She has generalized edema especially in her face and hands. She is complaining of “seeing spots” before her eyes and generally feeling ill. Vital signs are BP of 170/110, pulse 89, respiratory rate 20/min and oral temperature is 98.2 F. A urine specimen taken in the ER shows 2+ protein. She states no pain or discomfort in her abdomen and denies any sensations of contractions. She states no present discharge or leakage of fluid vaginally. The term you selected, "Preeclampsia", was CORRECT. Your selected action of "Admit to High Risk Antepartum Unit", was CORRECT. Explanation: The patient needs to be transferred to a high-risk Antepartum unit to rule out Preeclampsia and will require intensive assessment due to her lack of previous prenatal care. She is at high risk for seizures. This is a high-risk pregnancy with the signs and symptoms of Preeclampsia that are present as well as a lack of prenatal care. She needs immediate assessment and intervention to treat her condition. Rosie Holloway A G1P0 at 38 weeks is transferred to the Antepartum holding/testing area from her doctor’s office for monitoring and evaluation. In the office her cervix was 2-3 cm and 50% effaced. Earlier in the day, on admission, she had complained of irregular contractions and a persistent headache for the last 24 hours and decreased fetal movements as well as complaints of heart burn that had not been relieved with the OTC Tums. Blood pressures are 160180/90-100. After 2 hours on the monitor the uterine activity monitor shows regular uterine contractions every 2-5 minutes apart, with the patient complaining of pain with a 7 out of 10 pain scale. The fetal heart rate of 130 has minimal to moderate variability and an absence of accelerations. Nonreassuring decelerations are currently ABSENT. Many of the patient’s blood tests are pending; however, the labs that have been received are showing a low platelet count, elevated (ALT, AST) liver enzymes. Urine test is 2+ for protein. The patient’s cervix is examined again and is now 3-4 cm dilated and 80%. The term you selected, "HELLP Syndrome", was CORRECT. Your selected action of "Admit to Labor and Delivery Unit", was CORRECT.

Explanation: This patient should be transferred immediately to the labor and delivery unit. She is showing signs and symptoms of active labor as evidenced by her contraction strength, regularity, and, most importantly, her cervical change. What is most concerning are the present signs of a low platelet count, and elevated liver enzymes. She also complains of epigastric pain which could be signs of enlargement of the liver. All these signs and symptoms are common with the condition known as HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets). Due to her proteinuria and elevated blood pressure, preeclampsia must also be ruled out. The fetus is showing a lack of reactivity and must be monitored closely by an experienced RN in labor and delivery. Treatments are needed for the elevated blood pressure. The mother may require critical care if it is determined that she indeed has HELLP syndrome. Joey Kelly A G1P0 was admitted to the high-risk antepartum unit due to signs and symptoms of Preeclampsia yesterday. She has received Magnesium Sulfate IV and her blood pressure and reflexes have decreased. She is 41 weeks gestational age and an ultrasound has shown that the infant has intrauterine growth restriction. A nonstress test was done and the fetus is reactive, and movements are regular. The term you selected, "Induction of Labor", was CORRECT. Your selected action of "Admit to Labor and Delivery Unit", was CORRECT. Explanation: The patient should be transported to Labor and Delivery. This patient has exceeded the expected due date and the fetus is showing signs of growth problems due to the condition of Preeclampsia of the mother. It is most likely that now that the condition of the mother has been stabilized by the medication that she should be transferred to Labor and delivery for Induction of Labor. Chantel Foster A G4P2 at 38 weeks gestational age presents to the emergency department with active labor and a moderate amount of greenish fluid is noted leaking from the vaginal opening when her cervix is examined by the ER doctor and found to be at 5-6 cm. dilated and 80% effaced. Testing confirms that it is amniotic fluid. There is no foul odor to the fluid and the patient is afebrile.

She is having regular 60-90 second contractions every 5 minutes and her pain is an 8 out of 10 at the peak of each contraction. The Fetal heart rate is 130 with moderate variability with few accelerations. The term you selected, "Meconium Staining", was CORRECT. Your selected action of "Admit to Labor and Delivery Unit", was CORRECT. Explanation: This patient needs to be transferred and admitted to Labor and Delivery as soon as possible. The patient is most likely in the later stages of active labor and because she is multiparous, her labor will go much faster at this point as compared with the prim parous patient. She has experienced a spontaneous rupture of membranes (SROM). The assessed color of the amniotic fluid in the ER indicates a condition known as Meconium staining. This condition occurs when the fetus has its first bowel movement while still in the amniotic sac prior to birth probably due to stress in utero. Once the membranes have ruptured, and tests done to confirm that it is in fact amniotic fluid, it is ideal that the fetus be delivered in a 24-hour period if possible, to reduce the risk of infection from prolonged rupture of membranes. Special precautions must be taken to prevent aspiration of the meconium fluid as the infant is being born, and immediately after the birth of the baby. Tina White A G2P0 16-week gestational age patient arrives in the antepartum triage with complaints of premature painless contractions coming in an irregular pattern for the last 12 hours. The nurse receives orders from her physician to check the patient’s cervix. The nurse finds that the cervix is dilated to 3-4 cm with a bulging bag of membranes. The term you selected, "Incompetent Cervix", was CORRECT. Your selected action of "Prepare for Surgical Intervention or Cesarean Section", was CORRECT. Explanation: The patient requires preparation for a surgical intervention called a cerclage as soon as possible. At 16 weeks gestation, the fetus is not yet viable for extra uterine life. Putting a purse-string like suture to close the cervix is necessary to continue the pregnancy and prevent premature birth....