Maternal NB

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:

1. Administer Oxygen via nonrebreather face mask at 10-12L/min 2.Assist healthcare provider with administration of misoprostol (Cytotec) 1000 mcg rectally 3. Establish an additional IV line and anticipate additional crystalloids (Lactated Ringer's), colloids (albumin), blood and blood products 4. Continue to closely monitor vital signs, uterine fundus tone/level and vaginal bleeding 5. Anticipate healthcare provider insertion of postpartum balloon and/or return to operating room

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:

1. Educate patient regarding indwelling urinary catheter placement, Wash hands. 2 .Insert indwelling urinary catheter and connect to collection bag, secure to patient's thigh. 3. Measure urine return in collection bag; Reassess uterine tone, response to massage, level in relation to umbilicus, and position in abdomen. 4. Reassess vaginal bleeding and presence for clots; change underpads as needed. 5. Wash hands, document findings and completion of procedure.

Stephanie Gold Scenario 1 The nurse completes an initial assessment. T 37.4 C, 99.3 F; Heart rate 90, regular; RR 20, regular; BP 142/90 mmHg; FHR 145, moderate variability, 2 accelerations to 160 in 20 minutes, no decelerations. No contractions on electronic fetal monitoring or by palpation. Abdomen soft but tender in right upper quadrant. Urine negative for protein on dipstick. No vaginal bleeding or leaking of fluid. No pedal edema. DTR +3 bilaterally. Repeat blood pressure noted to be 144/90 mmHg. The HCP is notified of the assessment and orders are received. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

1. Explain all plan of care to client and significant other.Explanation of plan of care helps put client and significant other at ease, decrease anxiety. The must be done first. 2. Bedrest/side-lying position. 3. CBC, Chemistry Panel, LFT, 24-hour urine for protein and creatinine. 4. Continuous EFM. 5. Hourly VS and DTR.

Miranda Johnson Scenario 5 Baby boy Johnson is born at 1150 and immediately admitted to the NICU. His APGAR scores are low, he is lethargic, and in respiratory distress. Ms. Johnson is recovered for one hour and transferred to Postpartum where she is discharged after 3 days. Baby boy Johnson remained in the NICU for 10 days. After laboring Ms. Johnson, you are assigned 2 more patients, and decide to finish your charting on Ms. Johnson at the end of the shift or when you come in the next day. While catching up on your charting, you do not remember the exact details of Ms. Johnson's care. You document what you think happened and assume that you did everything according to protocol and written orders. You notice your co-worker charted on Ms. Johnson under your name and you do not have time to check to see if the charting is accurate. You have worked with this nurse for 2 years and assume her charting is accurate. At the age of 1, Baby boy Johnson exhibits developmental delays, abnormal muscle tone, and posture. He is diagnosed with CP (Cerebral Palsy). Ms. Johnson files a lawsuit for TEN MILLION dollars against both you and your hospital claiming NEGLIGENT care during her labor causing Baby boy Johnsons' CP. The hospital legal team, DON, CNO, and your manager call you into a meeting to get your statement. You do not remember much about that day because it has been a year ago. All you remember is that it was busy with back to back patients. Upon review of Ms. Johnsons' medical record, it is discovered that you were NEGLIGENT in the following: 1. Failure to monitor Ms. Johnson's vital signs per protocol 2. Failure to monitor Baby Boy Johnson's FHR rate according to protocol 3. Failure to intervene in a timely manner to correct Ms. Johnson's hypotensive event 4. Failure to notify both the Anesthesiologist and OB MD per protocol 5. Failure to document interventions, vital signs, assessments, and FHR per protocol 6. False documentation. Ms. Johnson wins the lawsuit and you lose your job and nursing license due to your gross negligence. Nursing care actions in order:

1. Maintain efficient, timely and continual factual and accurate documentation.Prevents possible documentation errors due to delay in charting. When care is provided and not documented in a timely manner, failure to document the care can put a patient at risk for getting a double dose of a medication(s), unnecessary treatments, or a discontinuity in medical care. o Prevents large gaps of time in the patient's chart which can be interpreted as a breach of duty in a lawsuit. 2. Thoroughly document factual and accurate information.Medical Records are legal documents used in medical malpractice lawsuits. Substandard improvised charting may be discovered and used as evidence to prosecute a nurse. 3. Discuss patient load with charge nurse.Communication is key to successful patient care. Patient safety is priority and can be compromised with unrealistic patient loads. 4. Always sign out when charting on a patient.Others can chart on your patient under your name. The medical record is a legal document and will be used against you in a medical malpractice lawsuit. Your documentation is your only defense. · NEVER let anyone chart under your name. 5. NEVER ASSUME ANYTHING your care or the care of others.

Miranda Johnson Scenario 3 At 0930 you are assigned another patient to triage and you ask a co-worker to watch over Ms. Johnson. At 1030 you assess Ms. Johnson who states "where have you been? I haven't seen a nurse for the past hour!" Upon assessment you note that she is having trouble breathing and feels like she is going to pass out. BP =85/50mmHg, HR=120bpm, R=28, Sp02 = 89%, lung sounds clear per auscultation. Skin is pale and clammy, sensory level is T6, and she is unable to move her body from her chest down. FHR is 100 BPM with late decelerations, no accelerations and minimal to absent variability. Contractions are every 2-3 minutes lasting 70-80 seconds and strong to palpation. You ask your co-worker to notify both OB MD and Anesthesiologist to report current situation. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

1. Turn epidural pump off.Stops infusion of epidural medication to resolve hypotension. 2. Lower HOB, elevate foot of the bed, and reposition patient to left lateral position.Increases blood flow to the heart and head leading to increased maternal blood pressure. · Left lateral positioning provides uterine displacement thereby increasing blood flow to the fetus. 3.Rapid infusion (bolus) of IV fluids.Increases intravascular volume to prevent cardiorespiratory arrest. 4. Apply nonrebreathing oxygen mask and set to 10L/minute per order.Corrects fetal oxygen deprivation by promoting uteroplacental perfusion. 5. Consider administration of Ephedrine.Vasopressors should be considered if other interventions have failed.

Miranda Johnson Scenario 4 At 1130 after admitting the new triage patient, you enter Ms. Johnson's room and notice Ms. Johnson continues to have episodes of hypotension with a nonreassuring FHR (Category 3). You ask your co-worker if she notified the OB MD and Anesthesiologist and she states that she did not have time. OB MD and Anesthesia are now notified by you and orders are received for a Stat C-Section. Signed informed Operative consent is on the chart. Ms. Johnson and her significant other are quickly educated on what to expect during the C-Section before being transferred to the OR. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

1. Continually monitor maternal vital signs and fetal heart rate.Allows for continual assessment of maternal hypotension and nonreassuring FHR and possibility of additional necessary interventions. 2. Administer Ephedrine per protocol for hypotension.Vasopressors are used for persistent hypotensive episodes following epidural medication administration. 3. Notify the charge nurse and nursery personnel of STAT C-Section.Charge nurse will notify OR team and provide additional nursing staff as needed. Nursery nurses will notify Neonatologist and gather necessary equipment for impending delivery. 4. Administer pre-op medications per anesthesia order.Nausea and vomiting frequently occur in patients undergoing cesarean section which could lead to aspiration. 5. Offer reassurance and emotional support to both mother and significant other.

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:

1. Reassess vital signs. 2. Set plain Lactated Ringers to Bolus rate on IV pump. 3. Administer Methergine 0.2 mg IM per healthcare provider order. 4. Assist healthcare provider with exam to assess for cervical or vaginal lacerations/hematoma or retained placental pieces. 5. Anticipate laboratory studies: CBC, blood typing and crossmatch, coagulation studies.

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:

1. Use therapeutic communication/active listening to assess patient's concerns and interest in pumping for colostrum 2. Consult Lactation Consultant or provide education to patient and assist with pumping. 3. Discuss with patient's partner for willingness/interest to feed baby colostrum. 4. Assist partner in feeding pumped colostrum and partner skin-to-skin contact. 5. Assess patient's ability to hold infant and assist patient with holding baby skin-to-skin after feeding for maternal-infant bonding.

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).

Physiological DescriptionYour ResponseExplanationRisk for Impaired Urinary Elimination TrueRelated to fetal head position and bladder compression.Risk for Maternal Injury TrueRelated to epidural insertion and potential side effects Safety DescriptionYour ResponseExplanationDeficient knowledge TrueClient has not had a child in 10 years and requires education.Fall, Risk for TruePatient is term in pregnancy and has a change in center of gravity.Impaired maternal newborn bonding, Risk for FalseNo indication.Risk for Ineffective Coping FalseNo indication.

Stephanie Gold Scenario 5 The tonic phase lasts 20 seconds and the clonic phase 30 seconds. The client is unresponsive for 1 minute after the seizure with long, deep respirations. No injury is apparent. The client awakes confused and combative. She is coughing large amounts of mucus and states, "What happened? My belly hurts!". SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

1. Asess vital signs and FHR pattern post seizure.Assess post-seizure status of both client and fetus. Fetal distress may occur from hypoxemia during the seizure. Monitor VS frequently until stable. 2. Continue oxygen at 10 L/min per mask.Next, administer oxygen to support oxygenation of the client and her fetus and resolve hypoxia. 3. Assess uterine activity and abdominal focused assessment.During the seizure the uterus may become hypercontractile and hypertonic. Membranes may rupture, cervix may dilate rapidly. The placenta may separate resulting in abruptio placenta. A rigid broad-like abdomen, pain, and tenderness could be signs of this condition. 4. Assess for incontinence, provide hygiene, insert indwelling urinary catheter.The client may be incontinent during the convulsion. Provide peri-care and insert and indwelling catheter with urinometer, for hourly output. Urinary output decreases when there is a reduction of glomerular filtration rate. Report output of < 30 mL/hour. 55Prepare to assist with the birth process/instruct client and significant other.The cervix may dilate rapidly during a convulsion as the uterus is hypercontractile and hypertonic. Eclampsia alone is not an indication for an immediate cesarean delivery- Route of birth is determined by labor progression, maternal and fetal condition, and gestational age. If abruptio placenta is confirmed with ultrasound and cervix is not dilated, cesarean birth would occur

Miranda Johnson Scenario 1 Upon entering patients' room, wash hands, introduce self to patient and significant other. Check arm bands of both patient and significant other and compare with Medical Record. Note additional armband for medication allergies. Confirm allergies with patient. Explain POC (Plan of Care) regarding pain management, answer questions, and address patients' concerns within scope of practice. Educate patient/family about the procedure used to insert the epidural catheter and PCEA (Patient Control Epidural Anesthesia) button. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

1. Review prenatal record with patient. Confirm pregnancy complications, allergies, and orders for epidural.It is the responsibility of each nurse assigned to the patient to review the patients prenatal record. Allows for planning and implementation of patient care. 2. Witness signing of epidural informed consent by Anesthesiologist and patient AFTER preanesthetic evaluation.It is the responsibility of the Anesthesiologist to assess the patient and to review and sign the Epidural consent. The nurses' role is to witness the patient's signature. Consents should be completed prior to any protocol care related to the epidural catheter. 3. Initiate IV bolus per order in preparation of epidural procedure.Helps to mitigate maternal hypotension that can result from a sympathetic blockade (epidural). Fluids should be initiated prior to epidural insertion to pre-hydrate client. 4. Gather epidural medications to include Ephedrine, per Anesthesiologist orders, epidural tray, crash cart, nonrebreathing mask, O2 tubing, and suctioning equipment.Epidural analgesia can cause severe hypotension, therefore, Ephedrine, a vasopressor, should be readily available to correct hypotension. Hypotension reduces the blood supply to the fetus causing oxygen deprivation leading to a non-reassuring FHR. Supplemental oxygen (100%) with a nonrebreathing mask at 10L is recommended to correct oxygen deprivation. o A severe reaction to epidural analgesia is cardiorespiratory arrest. A crash cart and suctioning equipment should be at the bedside during epidural infusion. 5. Monitor patient BP, Pulse, O2 Sat, and FHR during epidural procedure according to established guidelines.Vital signs should be assessed as follows: BP every 1-2 mins for 15 mins., after epidural bolus, then every 5-15 mins until epidural blockade wears off. MHR and FHR should be continuously monitored. Epidural analgesia can lead to sympathetic blockade, maternal hypotension, transient uteroplacental insufficiency, and alterations in the FHR.

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:

1. Assist 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. 2.Massage uterine fundus.Massaging the fundus until firm and tightly contracted closes off blood vessels at the placental site and stops bleeding. Call for help using emergency call system. 4.Set oxytocin rate to Bolus on IV pump as ordered by healthcare provider. 5. Assess 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.

Miranda Johnson Scenario 2 At 0810 Ms. Johnson is resting comfortably with the HOB (head of bed) elevated 30 degrees with a right hip roll in place. She tolerated the epidural without difficulty and now rates her pain as 2/10. She states she is feeling numbness in her vaginal area and down her legs bilaterally. Her sensory level is T10, and she moves all extremities without difficulty. BP is 120/75 mmHg, HR=80 bpm, R=18 breaths/min., even & unlabored, and SpO2 is 98%. Contractions are every 2-3 mins., lasting 60-80 secs., moderate intensity per palpation, (+) Accelerations and (-) Decelerations with minimal Variability (Category 1). SVE is 7cm dilated, 95% effaced and 0 station. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

1. Educate patient about the need for a urinary catheter. Insert Foley Catheter per protocol.Epidural analgesia decreases patients' ability to determine the need to urinate leading to urinary retention. A full bladder will also impede fetal decent into the birth canal. 2. Assess maternal and fetal wellbeing using vital signs, fetal heart rate and other parameters.Monitors maternal and fetal physiological response to labor and epidural to include hypotension, oxygen deprivation, and infection due to frequent vaginal exams and epidural insertion. Monitors physiologic response to active labor and epidural infusion. 3. Encourage repositioning every 30-60 mins. Keep HOB elevated 30 degrees and hip roll in place.Assists labor progression with fetal decent and deters unilateral epidural affects. HOB elevation of at most 30 degrees to prevent hypotension. Hip roll placement to prevent aortocaval compression. 4. Reassess patients' understanding of PCEA use.PCEA (patient controlled epidural analgesia) is the button that the patient can push periodically according to the pump setting entered by the Anesthesiologist. Strict instructions should be given to both the patient and family members that the patient is the ONLY person authorized to push the button. This decreases potential overdosing.

Stephanie Gold Scenario 3 The nurse reports these abnormal lab reports to the healthcare provider and receives orders to begin magnesium sulfate protocol (4 grams loading dose followed by 2 grams infusion) for HELLP syndrome and betamethasone 12 mg IM q24h x2. The nurse washes hands and applies gloves, verifies the medications and client with 2 identifiers. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

1. Educate the client and her significant other about the medication.Actively involving client in their own care is a safety strategy, decreases anxiety, and gives the opportunity for verbal consent of the treatment. 2. Initiate peripheral IV with Lactated ringer's infusing at 50 mL/hour.Magnesium sulfate is a high alert medication and should be administered as a secondary medication. A primary line is started with an isotonic solution, like Lactated Ringer's. To reduce the risk of pulmonary edema, total intake should be less than 125 mL/hour. 3. Piggyback magnesium sulfate solution into primary IV, set infusion at 400 mL/hour for 15 minutes; volume to be infused 100 mL.An initial loading dose of 4 to 6 grams over 15-30 minutes helps raise magnesium blood levels to a therapeutic level of 4-7 mEq/L and prevent eclamptic seizures. 4. IM betamethasone 12 mg.While the loading dose of magnesium sulfate is infusing, administer the IM steroid injection to enhance fetal lung maturity for gestations less than 34 weeks. Neonatal benefit is maximized when the interval between the first injection and birth is longer than 48 hours, but benefits begin within 4 hours of administration. The benefit of one injection is unclear but is often given without harm. 15Change infusion rate to 50 mL/hour Magnesium sulfate 20 grams/500 mL for the remainder of 400 mL.Followed by an hourly infusion of 2grams/hour. An infusion pump is used for accuracy and less risk of magnesium toxicity.

Stephanie Gold Scenario 4 Two hours into the magnesium infusion, the client states she has a "really bad" headache and she "can't see very well". Her eyes become fixed and her facial muscles begin to twitch. The nurse is monitoring fetal heart tones. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: Not all actions will be used.

1. Turn head to one side and ensure pillow under back and shoulder is snug.Keep airway patent and provide for safety from head injury. Side rails are up and padded. 2. Call for assistance but do not leave client. Keep family informed of situation.The nurse should call for help but do not leave the bedside. Informing the family helps lower anxiety. Eclamptic seizures are frightening to watch. 3. Administer oxygen via non-rebreather mask at 10 L/min.During the clonic phase of the seizure, the client will become apneic and may result in hypoxemia to the fetus. Respirations begin with long, deep inhalation. Having the 100% O2 in place will provide for additional oxygen to both mother and fetus. 4. Administer ordered 4 grams loading dose of magnesium sulfate IV in 15 minutes.Since eclampsia occurred after initiating magnesium sulfate, additional magnesium sulfate should be given. It is the drug of choice for treating eclamptic seizures and preventing repeated seizures. 5.Observe and document convulsion activity.Each stage of the convulsion should be timed and documented descriptively. 6. Administer IV lorazepam 2 mg over 3-5 minutes.Magnesium sulfate is the drug of choice over other antiseizure medications because it does not depress the gag reflex. Lorazepam or diazepam are only given if the client is receiving therapeutic levels of magnesium and experiences repeated eclamptic seizures.

Stephanie Gold Scenario 2 The nurse is admitting this client to the high-risk antepartum unit to monitor blood pressure and other assessments and to await lab findings. The nurse adds independent nursing actions to the plan of care. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

1Elevate and pad side rails.Her DTRs are +3 so she is slightly hyper-reflexic and at risk for seizures. Padding side rails protects her from injury if she has a seizure. Safety first! 12Ensure oxygen and suction are working properly.Airway and breathing precautions next. If client has a seizure, suction may be needed to clear airway. (She is already positioned on her side) During a seizure, client would have a period of apnea which would cause fetal hypoxemia. Applying oxygen to mother would increase oxygen available to fetus. Ensure both are working before needed in an emergency situation. 23Emergency medications brought to the client's room or verified as accessible.Magnesium sulfate, calcium gluconate, hydralazine, nifedipine are often in an emergency "toolbox" and brought to client's room for immediate access if needed; anticipating one or more of these meds will be ordered if complications such as preeclampsia, eclampsia, or HELLP syndrome occur. This is done as per agency policy. 34Bring extra pillows to enhance comfort in side-lying position and place between knees, behind back, and under abdomen.Enhancing comfort in the side-lying position will enable the client to maintain this position. Side-lying decreases pressure on the vena cava, increases venous return, placental and renal perfusion. Comfort measures are completed after emergency interventions. 65Bring bedpan, graduated cylinder, 24-hour urine container, ice into the room.Healthcare provider ordered 24-hour urine so bringing supplies for this collection would be necessary. The nurse may include intake and output in the care plan independently. At least 30 mL of hourly urine output demonstrates minimal kidney function. Left lateral position enhances renal perfusion, thereby decreasing angiotensin levels, and promotes diuresis. 24 hour I&O documents positive or negative fluid balance. 46Educate client and significant others about 24-hour urine collection, I&O and documenting oral intake.Educating and involving the client and significant others in the plan of care helps to decrease anxiety and empower them as important members of the health care team. Education occurs after other physiological needs are met.

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

Physiological DescriptionYour ResponseExplanationAcute Pain TrueStatus assessment reports lingering numbness from epidural.Bleeding TrueStatus assessment reports blood pooling under buttocks with large clots, most likely secondary to uterine atony because of multipara status, rapid second stage, oxytocin use and large infant.Deficient fluid volume related to uterine atony/postpartum hemorrhage TrueStatus assessment reports blood pooling under buttocks with large clots.Impaired mobility FalseStatus assessment reports effects continued numbness from epidural.Impaired patterns of elimination FalseStatus assessment reports continued numbness from epidural with urinary catheter having been removed previously; patient unable to sense a full bladder which can contribute to uterine atony and hemorrhage.Ineffective tissue perfusion related to hypovolemia TrueStatus assessment reports blood pooling under buttocks and large clots, feeling anxious and light-headed and appears paleInfection TrueStatus assessment reports no indication of a current infection.Nausea TrueStatus assessment reports no indication of increased risk. Safety DescriptionYour ResponseExplanationDeficient knowledge TrueStatus assessment reports patient reports feeling wet and may have urinated on self and still numb from epidural; unaware of potential for uterine atony and hemorrhage, client and husband both require education and support.Disturbed sensory perception TrueStatus assessment reports patient is still numb from epidural.Fall, risk for self and risk for dropping baby TrueStatus assessment reports lingering numbness from epidural and unable to move legs; reports feeling light-headedImpaired maternal newborn bonding FalseStatus Assessment reports mother is currently holding and breastfeeding baby.Peripheral Neurovascular Dysfunction FalseStatus assessment reports no indication of increased risk.

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.

Physiological DescriptionYour ResponseExplanationDeficient Fluid Volume FalseStatus assessment reports no generalized edema from fluid shift from intravascular to extravascular at this assessment/nausea not significant enough to cause deficit.Imbalanced Nutrition TrueStatus assessment reports assessments do not show nutrition has been substantially impacted by slight nausea.Injury, risk for fetal TrueStatus assessment reports r/t risk for uteroplacental insufficiency secondary to vasospasm if abdominal pain and malaise/elevated BP indicate preeclampsia/HELLP syndrome.Injury, risk for maternal TrueStatus assessment reports r/t hypertension and vasospasm and potential decreased renal perfusion.Nausea TrueStatus assessment reports experiencing slight nausea off and on this week. Safety DescriptionYour ResponseExplanationFall Risk TrueStatus assessment reports r/t shifting center of gravity at 32 weeks gestation and in the third trimester.Injury, risk for maternal TrueStatus assessment reports r/t risk for worsening preeclampsia to eclampsia and seizures. Love and Belonging DescriptionYour ResponseExplanationAnxiety TrueStatus assessment reports r/t unknown impact of current complication on mother and fetus.Disabled Family Coping FalseStatus assessment reports no evidence of inappropriate family coping. Boyfriend accompanies. Risk for r/t High Risk Pregnancy and Financial Concerns.Health Maintenance; Ineffective TrueStatus assessment reports r/t deficient knowledge about high risk pregnancy.