MOM/BABY swift river
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: 1Place bed in Trendelenburg position.Assists in relieving pressure of fetal head on cervix, preventing premature cervical dilation; helps in slowing or preventing continuing leaking of amniotic fluid. Fetal safety is critical. 2Discuss plan of care with patient; answer questions honestly, especially concerning SROM and implications for preterm labor and birth.Provision of clear information facilitates compliance with plan of care and can allay anxiety. 3Assess support systems available to woman.Assistance and caring by significant others are important during stressful events. 4Apply sequential compression device (SCD) boots and connect to machine.Prevents the formation of blood clots secondary to immobility. 5Begin Intake and Output (I&O) chart and document every shift.Ensures adequate hydration and balanced elimination.
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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: 1Inspect perineum.Possible umbilical cord prolapse with gush of amniotic fluid and small, preterm fetus. Patient states she "feels like something came out of her vagina." Inspection for prolapsed cord is the quickest assessment that can be performed. 2Assess FHR for bradycardia.Occult prolapse of umbilical cord cuts off blood flow to fetus, causing bradycardia and potential fetal death. Significant changes in the fetal heart rate may indicate a hidden or occult prolapsed cord. 3Assess vital signs, including temperature.Increasing temperature indicates infection or chorioamnionitis. 4Assess for contractions; palpate fundus.On-going vigilance for signs of preterm labor; palpation can detect contractions not detected by monitor or recognized by woman. 5Assess for foul odor to amniotic fluid; perform pericare and provide fresh underpads.Indicative of infection or chrioamnionitis; provides comfort and prevents infection.
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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: 1Perform Non-Stress Test (NST) now and bi-weekly BPP and every shift; teach woman to do Daily Fetal Movement Counts (DFMCs).Reactive NST indicative of fetal well-being; slowing of fetal movement is a sign of fetal compromise. Biophysical Profile (BPP) builds on the NST with fetal ultrasound to evaluate a babys heart rate, breathing, movements, muscle tone and amniotic fluid level. The NST is performed now and each shift to identify signs of fetal compromise 2Administer Betamethasone 12 mg IM for two doses 24 hours apart.Stimulates fetal lung maturity by promoting release of enzymes that induce production or release of lung surfactant. 3Administer a broad-spectrum antibiotic (e.g., ampicillin, erythromycin) and continue for 7 days.Treat infection, decrease incidence of chorioamnionitis while allowing an additional 24 hours to elapse after administration of Betamethasone. 4Request neonatologist to visit patient.Affords opportunity to discuss care of infant if born preterm; allays fear and anxiety. 5Assess results of daily CBC.Increasing WBC indicative of infection.
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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: 1Encourage vocalization of fear and concerns.Can help allay anxiety and identify coping behaviors. 2Cluster nursing care activities as much as possible, such as medication administration, assessments, and vital signs.Promotes opportunity for woman to obtain rest without interruptions. 3Offer diversional activities: watching TV, reading, crossword puzzles, small needlecraft activities. Request family to bring articles from home to "decorate" hospital room.Assists in refocusing energy; helps cope with decreased mobility; decreases anxiety; provides some degree of "normalcy" during stressful time. 4Teach conscious relaxation and breathing techniques.Non-pharmacologic techniques that promote relaxation and decreases tension. 5Provide comfort measures such as back rubs, position changes, and aromatherapy.Decreases muscle tension and fatigue and promotes feeling of well-being.
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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: 1Assist mother to unlatch infant from breast and place infant in crib or hand to the husband.Patient is light-headed and hypovolemic putting infant at risk of falling from mother's arms. Infant safety is a first priority. 2Massage uterine fundus.Massaging the fundus until firm and tightly contracted closes off blood vessels at the placental site and stops bleeding. 3Call for help using emergency call system.Postpartum hemorrhage is the leading cause of morbidity and mortality requiring a rapid, team approach to patient management. 4Set oxytocin rate to Bolus on IV pump as ordered by healthcare provider.Rapid infusion of oxytocin causes a sustained contracted uterus, thereby clamping off blood vessels from placental site and preventing hemorrhage. 5Assess bladder status and need to perform straight catheter.A full bladder displaces the uterus and contributes to hypotonia and uterine atony. Her uterus is slightly deviated to the right, indicating a potential need for catheterization.
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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: 1Educate patient regarding indwelling urinary catheter placement, Wash hands.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 first step. 2Insert indwelling urinary catheter and connect to collection bag, secure to patient's thigh.Insertion of Indwelling urinary catheter is done according to established protocols, under sterile technique and is the second step. The patient is unable to void, and a full bladder is a common cause of uterine atony and early postpartum hemorrhage. 3Measure urine return in collection bag; Reassess uterine tone, response to massage, level in relation to umbilicus, and position in abdomen.Assesses adequate emptying of bladder; emptying bladder returns uterus to normal and position and facilitates normal contraction of the uterus. 4Reassess vaginal bleeding and presence for clots; change underpads as needed.A firmly contracted uterus clamps off blood vessels at the placental site, preventing uterine atony and excessive bleeding, changing underpads for patient comfort and prevention of infection. 5Wash hands, document findings and completion of procedure.Prevents spread of infection; accurate documentation is to be performed after patient care is performed, NEVER BEFORE!
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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: 1Reassess vital signs.Indicates physiologic response to fluid resuscitation and uterotonic meds, BP must be assessed prior methergine administration. 2Set plain Lactated Ringers to Bolus rate on IV pump.Next the nurse must address fluid resuscitation to treat hypovolemia and fluid loss. 3Administer Methergine 0.2 mg IM per healthcare provider order.Methergine causes a sustained firm contraction of the uterus, clamping off blood vessels at the placental site, decreasing excessive bleeding. 4Assist healthcare provider with exam to assess for cervical or vaginal lacerations/hematoma or retained placental pieces.Unrecognized cervical/vaginal lacerations from a rapid second stage labor and large fetus can be the cause of excessive vaginal bleeding, especially with a firm fundus. 5Anticipate laboratory studies: CBC, blood typing and crossmatch, coagulation studies.Laboratory studies reveal degree of hemorrhage, coagulopathies which can cause hemorrhage and aid in patient management.
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