Maternal-Newborn SR

Kesha Jackson Scenario 2 The nurse is considering the potential care of Kesha if it is determined that she is in preterm labor. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Assess FHR and contraction pattern per monitor. Perform sterile cervical exam to determine dilation, effacement, and station. Obtain urinalysis and lab work such as CBC. Administer IV fluids and/or antibiotics. Consider administration of tocolytics.

Jenny Smith Scenario 6 Jenny is awake and alert and wants to go home. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Assess Jenny's current status/physical readiness for discharge. Verify blood type. Educate about follow-up with provider. Educate about warning signs of complications. Offer support for pregnancy loss.

Ms. Susie Smith Scenario 3 30 minutes later, the monitor tracing reveals uterine irritability, but no contractions present. Per healthcare provider order , it is time to increase the rate of the oxytocin. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Assess contraction pattern and palpate uterine resting tone. Assess fetal status. Reassess maternal vital signs. Increase oxytocin to 2 mu/minute per healthcare provider order. Educate and reassure the client.

Aminiah Hussain Scenario 4 The certified nurse midwife answers the husband's questions about the induction process and protocol. Dr. Hussain signs the written consent for his wife. The midwife, Beth, performs a speculum exam and it is found to be positive for pooling of clear amniotic fluid, positive Nitrazine and positive Ferning to confirm rupture of membranes. The cervix is soft, anterior, and 2 cm dilated, 50% effaced, -1 station. Bishop score is 8 showing cervix favorable for induction. Orders given by Certified Nurse Midwife for induction with oxytocin protocol. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Assess fetal status with continuous electronic monitoring and evaluate/document every 15 minutes and with every change of oxytocin dosage. Assess contraction pattern and resting tone every 15 minutes and with every change of oxytocin dosage; document. Initiate primary IV with Normal Saline solution. Oxytocin 30 units/500 mL Normal Saline IV through secondary line at 1 mu/min by infusion pump at 1 mL/hr. Increase by 1-2 mu/min, every 30-60 minutes, based on the woman, fetus, and progress of labor. Assess BP, pulse, respirations every 30-60 minutes, and with every change of oxytocin dosage; document.

Ms. Susie Smith Scenario 2 Ms. Smith verbalizes understanding of purpose and process of the oxytocin Contraction Stress Test (CST). She appears much calmer and states she is ready to proceed with initiating the test. You assemble the needed supplies at her bedside; a standard concentration of 500 ml Lactated Ringer's with 30 units oxytocin is used. After washing your hands, and donning non-sterile gloves, you are ready to proceed with CST. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:Assess maternal vital signs.

Assess maternal vital signs. Assess FHR baseline and reactivity. Assess monitor tracing for presence of contractions, palpate uterine fundus for contractions. Obtain IV access with #18 gauge IV catheter and begin 1000 ml Lactated Ringer's solution at 125 ml/hour on IV pump. Administer oxytocin intravenously through a secondary line connected to the main line at the proximal port with an IV pump; begin at 1 mu/min per healthcare provider prescription.

Jenny Smith Scenario 2 You respond to Jenny's call light going off. Upon entering the room, she is holding her abdomen and complaining of increased pain. She describes it as cramping and rates it 10/10. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Assess vital signs. Assess amount of current vaginal bleeding. Administer pain medication as prescribed Educate about spontaneous miscarriage and about medication action and effects and evaluate understanding. Document event in the chart.

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:

Continually monitor maternal vital signs and fetal heart rate. Administer Ephedrine per protocol for hypotension. Notify the charge nurse and nursery personnel of STAT C-Section. Administer pre-op medications per anesthesia order. Offer reassurance and emotional support to both mother and significant other.

Aminiah Hussain Scenario 5 Eight hours later, the oxytocin dosage is at 16 mu/min (16 mL/hr). Aminiah's vitals: T 37.4 C, 99.3 F, Pulse 94 bpm and regular, BP 128/84 mmHg. Pain level 8/10 with some involuntary "grunting" at the peak. Client has tears coming down her cheeks. Her husband is pacing in room. The midwife rubs her back and coaches her in breathing. FHR baseline 145 with moderate variability. Contraction pattern: q2min, 90 second duration, strong. There have been 6 contractions in 10 minutes. Fetal heart tones decelerate to 80 beats/minute during the contraction but does not return to baseline at the end of the contraction. The midwife conducts a sterile vaginal exam to check for cervical dilation and assess for umbilical cord prolapse. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Discontinue the oxytocin infusion. Reposition the client to the other side. Administer oxygen via nonrebreather face mask at 10 L/min. Administer IV fluid bolus of 500 mL/hr. Administer terbutaline 0.25 mg subcutaneously.

Jenny Theriot Room 304 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.

Educational Needs Increased acuity Status assessment reports leaking of fluid from vagina, possible contractions and preterm delivery. These should be the subject of teaching and support for the client. Fall Risk Increased acuity Status assessment reports the client is pregnant; this changed her center of gravity and balance. Health change Increased acuity Status assessment reports leaking of fluid from vagina and possible contractions. Pain level Normal acuity Status assessment does not indicate report of pain. Physiological Needs Increased acuity Status assessment reports leaking of fluid from vagina, possible contractions. Sensorium Needs Normal acuity Status assessment reports no indication of changes in sensorium.

Jenny Smith Scenario 4 Jenny's HR is 120, bp 96/48 mmHg, Oxygen saturation 99% on room air. Her pain and bleeding remain increased. It has been determined that Jenny is continuing to bleed heavily and needs to go to surgery for a dilation and curettage. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Explain to Jenny about the plan of care. Ensure that the consent is obtained prior to the surgery. Assess NPO status to ensure that she has been NPO for the proper period of time.If the patient has not been NPO long enough, the surgery may be pushed back to allow sufficient time to pass. If it is determined that she needs to go regardless of NPO Administer pre-op medications as indicated. Give report to the operating room staff and ensure support is given to the client related to perinatal loss.

Renee Workman Scenario 5 Ten (10) minutes into the magnesium loading dose infusion the client states "I feel so hot I can't stand it!" Her spouse says, "Look how red her face is! What is happening? I'm so scared!" SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: Not all responses will be used.

In a calm voice, remind the client and her wife that this is an expected side effect of the magnesium sulfate related to vasodilation. Use therapeutic touch and dim the lights in the room. Provide the client with a cool washcloth for her forehead; cover the client with sheet only and offer a fan. Assess the client's vital signs and document FHR. Ask the wife to leave the client's room. Notify the healthcare provider of the adverse effects of the medication. (not used)

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:

Inspect perineum. Assess FHR for bradycardia. Assess vital signs, including temperature. Assess for contractions; palpate fundus. Assess for foul odor to amniotic fluid; perform pericare and provide fresh underpads.

Sarah Lane Scenario 4 After 10 additional minutes of monitoring, a few fetal movements are noted on monitor tracing and indicated with remote event marker. One FHR acceleration of 10 BPM above the baseline is noted. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Reassess fetal position using Leopold's Maneuver and placement of transducer. Extend testing time for an additional 20 minutes. Educate patient and husband on the use of vibroacoustic stimulation procedure. Monitor for 5 minutes before stimulation. If baseline remains nonreactive, activate vibroacoustic stimulation device for three seconds on maternal abdomen over fetal head.

Renee Workman Scenario 4 The nurse reviews the lab reports and notifies the HCP and gives report in SBAR. SELECT THE FIRST TWO NURSING ACTIONS (situation (S) and background (B))IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Renee Workman, blood work results reveal HELLP syndrome.Situation Renee is 36 weeks gestation, came to clinic today due to decreased fetal movement.Background NST reactive but minimal variability. BP ranging 148-160/96-100. +3 DTRs. HA and blurry vision remain.Assessments What magnesium sulfate loading dose and infusion rate would you like to start Renee on? Read back HCP prescription: Magnesium Sulfate 4-gram loading dose in 15 minutes followed by 2 gram/hour.Repeat back verbal/phone prescriptions for accuracy.

Sarah Lane Scenario 5 Following an additional 20 minutes of testing, along with 2 additional applications of vibroacoustic stimulation, two accelerations lasting at least 15 seconds and peaking at least 15 beats/min above the baseline are noted on monitor tracing. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Review monitor tracing and interpret NST results Consult with prescribing healthcare provider regarding assessment findings and NST interpretation. Educate woman and husband on NST results. Schedule woman for follow-up NST (twice-weekly) if delivery has not occurred. Document performance of procedure, patient tolerance, and collaboration with healthcare provider regarding interpretation of results.Accurate documentation is done after performance of patient care.

Renee Workman Scenario 2 Assessment data: T 36.5 C, 97.2 F, Pulse 88 and regular, BP 150/94 R arm, 148/96 L arm. Baseline FHR 144. Reactive NST with no fetal decelerations. Heart sounds regular, no heart murmur or extra sounds. Breath sounds clear bilaterally +3 peripheral edema, +3 reflexes. States pain level 5/10- "headache increasing". Labs are ordered and drawn, and intravenous access is obtained. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Turn the client to her left side and offer prescribed acetaminophen. Elevate and pad side rails. Apply oxygen at 10 L/min per mask. Emergency medications brought to the client's room/verify accessibility. Notify healthcare provider of assessments.

Kesha Jackson Scenario 1 Kesha is currently on the fetal monitor undergoing a non-stress test. FHR is 130 baseline, moderate variability, no decelerations, but is not having accelerations, with some interruptions in the tracing. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Assure that the monitor is tracing fetal heart rate consistently. Adjust fetal heart rate monitor. Give mother some cold juice to drink. Reposition mother to left lateral position. Request ultrasound for biophysical profile.

Jenny Smith Scenario 3 When making rounds, you check in on Jenny. She states that she has had an increase in vaginal bleeding, is "feeling dizzy, and that she does not feel well. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Assess vital signs. Assess vaginal bleeding amount and odor. Estimate and compare previous and current blood loss. Notify the healthcare provider. Document findings and notification of healthcare provider.Documentation should be done last to include all the information.

Renee Wilson Scenario 5 Infant is delivered through a low transverse incision and handed to the Neonatal Nurse Practitioner (NNP). SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Assist in drying infant and place on a pre-warmed radiant heat warmer. Perform Apgar Score at 1 and 5 minutes of age. Assess vital signs; perform brief physical assessment. Place matching ID bands on infant, mother and father. Place infant skin-to-skin on mother's chest with father at her side; cover infant with warm blanket.

Maria Sanchez Scenario 4 Maria calls the OB desk the next day and states she and Juan are doing better. She asks if someone can make sure they are "doing it right." She states she is getting too much "help" from her mother. Maria's mother takes the baby from her and gives him a bottle whenever they struggle even for a few minutes. "How do I know if Juan is getting enough milk from me?" (Juan is now 4 days old). SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

"Juan should have 6-8 wet diapers of light-yellow urine every 24 hours. It's a good idea to write them down to help you remember." "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." "Juan latches easily, has bursts of suck/swallows, you hear him swallow, easily releases the breast after 15-20 minutes, and appears content at the end of the feeding." "You feel Juan tug at the breast but no pain, you have some uterine contractions and maybe a little bit of vaginal bleeding during the feeding, you are thirsty and feel relaxed, and your breasts feel lighter or softer at the end of the feeding." "You can bring Juan into the clinic for Baby Weigh-In and have his weight checked. You can also talk to the lactation consultant. She can even observe a feeding to help you."

Maria Sanchez Scenario 5 Maria calls the OB unit. Her voice is high-pitched and she seems anxious. She states, "My baby Juan is 10 days old. He breastfeeds all the time- he acts like he is hungry and not content for more than 1-2 hours! I am exhausted. I have been keeping the diary like you said and he has 5-6 wet diapers and a couple of stools each day. I sometimes hear him swallow after he takes several sucks. He falls asleep after about 15 minutes on one breast. I feel him tug at my breast but it hurts my nipple sometimes too! My other breast is still full but it doesn't leak; I only get 1 oz when I pump! My mother thinks I should just give him formula. My grandmother contacted the family curandera (female healer) and she suggested an herbal tea to increase my milk supply. I want to make an appointment with the lactation consultant but I can't wait in a waiting room. My grandma is afraid of "mal aire" (bad air) that might enter mine or the baby's body in the waiting room. I am so confused. I don't know what to do! I have read about all of the good things breastfeeding does for me and Juan. What can I do to increase my milk supply and keep breastfeeding? SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

"Maria, take 3 deep breaths in and exhale slowly while I count to 3." "An appointment can be made for first thing in the morning so you do not have to wait in the waiting room at the lactation clinic. The lactation nurse is an expert and will be able to help you." "You are a good mother, Maria. You are doing an excellent job of keeping the feeding diary and trying many options to help your baby. Bring your feeding diary with you to your appointment." "Spend time with Juan skin-to-skin before attempting to latch-on for feeding. Undress Juan down to his diaper to help him wake up for the second breast. Express milk using the pump if he doesn't feed 20 minutes on each side." "Sleep when Juan sleeps. Tell your mother and grandmother they can help you best by fixing meals and doing household chores so you can rest."

Maria Sanchez Scenario 3 After Maria, Raul and Juan have been home for 24 hours, the nurse makes a follow-up phone call to Maria. She is in tears and states she is unable to get Juan to eat from the breast. She has tried several times but ended up giving Juan a bottle. She is asking for assistance with latch on. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

"Position your baby skin-to-skin with you for a few minutes." "Hold your baby like a football." "Roll your nipple between your thumb and index finger so it stands out. Express a drop or two of milk." "Support the breast with thumb on top and 4 fingers underneath the breast." "Tickle your baby's bottom lip with the nipple. Watch for him to open wide, then quickly bring him to the breast."

Renee Wilson Scenario 2 Two hours later contractions continue at every 2 minutes, lasting 60 seconds, and she states they "feel about the same". She is sitting in the rocking chair and states that she feels like she may be leaking fluid. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Assist woman to bed; reassess FHR baseline and reactivity. Using a sterile gloved hand, test fluid leaking from vagina with Nitrazine paper. Assess color and character of amniotic fluid. Assess contraction pattern and palpate uterine resting tone. Reassess maternal vital signs, including temperature; assess temperature every two hours.

Cindy Mason Scenario 4 Mrs. Mason calls out and states she has an urge to push. She is doing pant-blow breathing and is sitting on the birthing ball. Assessment findings: BP 128/78 mmHg, P. 90 beats/minute, R, 28 breaths/minute, FHR 144 baseline with moderate variability, +accelerations, no decelerations (Category 1). Sterile vaginal exam: 10 cm, 100%, +1 station. Her healthcare provider is present and ready for delivery. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Assist woman to birthing bed and place in lithotomy or side-lying position for birth. Request assistance for room set up and for delivery. Ensure neonatal resuscitation equipment readily available. Encourage woman to push spontaneously when she feels the urge to do so rather than directed pushing Encourage deep breaths and relaxation in-between each contraction

Renee Wilson Scenario 4 Four hours later the oxytocin is infusing at 18 mu/min. Contractions are every 2 minutes, lasting 60 seconds and moderate intensity per palpation. FHR baseline has increased to 170 bpm with minimal baseline variability (Category II). Sterile vaginal exam conducted by healthcare provider reveals no change from earlier exam: 6cm, -2 station. An emergency C-Section is called. Operative consent is on chart; operating room team assembled, including the Neonatal Nurse Practitioner (NNP) to care for infant. Mrs. Wilson and her husband are quickly educated on what to expect during C-Section. She is transferred to the OR per stretcher accompanied by her husband. Following administration of a spinal anesthetic she is placed in a supine position with slight left lateral tilt. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Assess FHR before removing transducer; cleanse abdomen with chlorhexidine wipes. Insert Foley catheter. Apply sequential compression device (SCD) boots to calves; secure legs to OR table with strap. Perform lap, needle and instrument count with OR tech prior to start of case and at established intervals. Perform Time-Out.

Jenny Smith Scenario 5 You have received Jenny back after her procedure. The OR nurse reported that there were no complications with the surgery, last set of vital signs were 98.9oF., Heart rate 102 beats/minute, 16 breaths per minute, BP 112/78 mmHg, Oxygen saturation 98% on room air, there was minimal bleeding on her pad (<5mL) and she is due to urinate prior to discharge. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Assess Jenny's current vital signs. Assess current bleeding. Assess current urinary output. Speak with Jenny and inform her that she is back in her room and that she is doing well. Assess her current pain level. Inform Jenny that her family is waiting and offer to bring them in to be with her.

Cindy Mason Scenario 2 Client's assessment findings: BP 110/70 mmHg, P. 86 bpm, R. 22 breaths/minute, T 97.8o F., SAO2 100%, contractions every 3 minutes, lasting 60 seconds, moderate intensity per palpation, FHR 140 baseline, moderate variability, + accelerations (Category 1). Sterile vaginal exam: 5 cm, 90%, -1 station, spontaneous rupture of membranes confirmed with a positive Nitrazine, slight bloody show, pain 4/10. Healthcare provider was notified of assessment and orders are received to admit to the LDR with ice chips and clear liquids allowed. Mrs. Mason is transferred to the LDR and report given to labor nurse. Mrs. Mason states that the contractions are getting stronger and requests suggestions on additional coping techniques. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Assess fetal status and contraction pattern according to stage and phase of labor. Reassess maternal vital signs, including temperature; assess temperature every two hours. Assess color and character of amniotic fluid. Encourage ice chips and clear liquids such as apple juice, popsicles. Encourage frequent position changes and hydrotherapy in shower

Carly Madison Scenario 4 Two hours later Mrs. Madison is successfully using her breathing and relaxation techniques and reports her pain level at 5/10. Her husband is providing massage to assist with pain management. She reports increased vaginal pressure and is experiencing a moderate bloody show with clear amniotic fluid. Sterile vaginal exam (SVE) reveals no cervical change. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Assess fetal status using electronic fetal monitor and review tracing. Assess contraction pattern and palpate uterine resting tone. Re-assess maternal vital signs. Increase the oxytocin by 2 mu/min per healthcare provider prescription. Praise woman and her husband for coping with contractions.

Renee Wilson Scenario 1 You enter the patient's room. After washing and gloving hands, you identify yourself and the patient, Mrs. Renee Wilson. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Discuss C-Section as an alternative method of childbirth. Allow the woman to verbalize feelings and thoughts regarding potential for C-section. Praise woman and husband for efforts in use of non-pharmacologic labor techniques. Encourage frequent position changes and hydrotherapy in shower. Suggest changing to a more complex breathing technique since pain is rated at 5/10.

Ms. Susie Smith Scenario 1 You enter the patient's room. After washing and gloving hands, you identify yourself and the patient, Ms. Susie Smith. Assessment findings: Vital signs: BP 144/90 mmHg, P 88 bpm, R 22 breaths/minute, FHR 134 baseline with moderate variability, no accelerations noted. No visible contractions on monitor tracing. Ms. Smith is teary and asks if her baby is going to be alright. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Discuss with woman fears about baby health; offer reassurance. Educate woman on oxytocin contraction stress test (CST) procedure. Have woman empty her bladder. Position woman in Semi-Fowlers position with left lateral tilt. Reassess placement of tocodynamoneter and transducer.

Kesha Jackson Scenario 3 After a speculum exam to confirm Kesha has not prematurely spontaneously ruptured membranes, a fetal fibronectin is sent and comes back negative. A group beta strep (GBS) culture is sent. Kesha's contractions have now stopped after treatment with tocolytics. Cervical exam reveals that she is 0.5 cm dilated/ 25% effaced/baby is a -3 station. A bedside ultrasound shows that the baby is in vertex position. Cervical length ultrasound shows that the cervix is 2.0 cm. It has been determined that she is at significant risk for preterm labor to occur again and it has been recommended to give her steroids for fetal lung development. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Educate Kesha about steroids and the need to administer them. Verify that she understands the rationale to receive the medication using the teach back method. Verify the 5 rights of medication administration. Prepare steroids as ordered by the healthcare provider. Choose large muscle for injection and offer ice to site. Establish a plan with Kesha to receive the second required dose of steroids in 24 hours. If discharged, she may have trouble getting transportation and need assistance.

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:

Educate patient about the need for a urinary catheter. Insert Foley Catheter per protocol. Assess maternal and fetal wellbeing using vital signs, fetal heart rate and other parameters. Encourage repositioning every 30-60 mins. Keep HOB elevated 30 degrees and hip roll in place. Reassess patients' understanding of PCEA use.

Renee Wilson Room 302 Renee Wilson, 26 y/o G1P0 admitted four hours ago to the Birthing Center. She has had an uncomplicated pregnancy, but her obstetrician has expressed the concern about needing a c-section because of the anticipation of a large baby. Her last ultrasound estimated fetal weight at 9 lbs. 6 oz. She and her husband have attended Lamaze Prepared Childbirth Classes and their Birth Plan includes the desire to have an unmedicated labor and vaginal birth. She also desires skin to skin contact with her baby at birth and breastfeeding. Admit assessment findings: Sterile vaginal exam (SVE) - 4 cm, 80% effaced, and fetal vertex at a -2 station with intact membranes, slight bloody show. BP 110/70 mmHg, P. 88 beats/minute, R 24 breaths/minute; T 98.8 F. 37.1 C. FHR 150 baseline with moderate variability + accelerations, absent decelerations (Category 1). Contractions are occurring every 2 minutes, lasting 60 seconds with moderate intensity per palpation. Portable tocodynamometer and fetal ultrasound transducer are in place. She is using shallow-chest breathing and conscious relaxation techniques and is ambulating in her room. She rates her pain at 5/10. She tells you that she will feel like a failure if she can't deliver vaginally.

Educational Needs Increased acuity Fall Risk Increased acuity Health change Increased acuity Pain level Increased acuity Physiological Needs Increased acuity Sensorium Needs Normal acuity

Cindy Mason Room 304 Cindy Mason, 28 y/o G2P1 at 40 weeks gestation. She and her husband present to OB Triage with complaint of early labor. Her prenatal history indicates an uncomplicated first pregnancy with a spontaneous vaginal delivery. Her current pregnancy has also been uncomplicated with no risk factors identified. She and her husband have attended Lamaze Prepared Childbirth classes and their Birth Plan indicates a desire for an unmedicated labor and birth and breastfeeding. Mrs. Mason states her contractions are occurring every 4 minutes and lasting 60 seconds. She is using slow-chest breathing and rates her pain at 4/10. She also reports leaking clear fluid from her vagina. She believes the leaking began about two hours ago.

Educational Needs Increased acuity Fall Risk Increased acuity Health change Increased acuity Pain level Increased acuity Psychological Needs Increased acuity Sensorium Needs Normal acuity

Maria Sanchez Room 305 Maria Sanchez, 20-year-old female, G1 P1 L1, 39 weeks gestation. Pregnancy uncomplicated. O+, Rubella immune, Group B Strep negative. NKDA. 12-hour 1st stage, 1 hour 2nd stage, 10 minute 3rd stage. Spontaneous vaginal delivery with 1st degree perineal laceration one hour ago. Vital signs stable; fundus firm, midline, at umbilicus; Lochia rubra moderate, no clots; Up to bathroom x1- 500 mL, no dysuria, instructed on peri-care; Legs still a little "tingly" but able to bear weight with assist X2. Pain level 3/10- ice to perineum with relief. Neonate male- Juan- 3500 g; Apgar 8 & 9; T 36.8 C, 98.2 F; AP 156 beats/minute, regular; R 52 breaths/minute, irregular. Skin-to-skin with mother for first hour. Beginning to show hunger cues. Their plan is do both breast and bottle feeding; "las dos cosas." Maria's husband Raul is a quiet presence. Her mother, grandmother, and older sister were Maria's support persons in labor. Maria and Raul are bilingual in English and Spanish. They were both born in the US- are Mexican Americans. Her mother speaks and understands more English than her grandmother does.

Educational Needs Increased acuity Fall Risk Increased acuity Health change Increased acuity Pain level Increased acuity Psychological Needs Increased acuity Sensorium Needs Normal acuity

Renee Workman Room 306 Renee Workman, Renee Workman, 35-year-old African American female, G2 T0 P0 A1 L0, 36 weeks gestation, history of In Vitro Fertilization with one failed implantation. Otherwise uncomplicated pregnancy. Reported decreased fetal movement today. BP of 144/92 in office. Weight up 2 kg in 2 weeks since last appointment. Urine +1 protein on dipstick. Mild headache and slightly blurry vision. No contractions, leaking of fluid or vaginal bleeding. Wife accompanies client.

Educational Needs Increased acuity Fall Risk Increased acuity Health change Increased acuity Pain level Increased acuity Psychological Needs Increased acuity Sensorium Needs Normal acuity

Aminiah Hussain Room 303 Aminiah Hussain, 22-year-old Muslim female, G1 T0 P0 A0 L0, 39 5/7 weeks gestation. NKDA. Pregnancy uncomplicated. Woke up early morning feeling wet; wasn't sure if leaking urine or membranes ruptured. Has continued to stay wet and needed to wear a pad for the last 4 hours. No contractions or vaginal bleeding. Her husband, Mohammad, is with her. He is attending his first year of medical school at the University and both are in the United States on VISAs. He called the obstetrics office and the certified nurse midwife told them to come to the hospital for evaluation and possible induction of labor. Aminiah looks to her husband to answer questions. He reads English fluently but both Aminiah and her husband struggle to speak and understand English conversation. Both appear nervous and have a lot of questions about an induction.

Educational Needs Increased acuity Fall Risk Increased acuity Health change Increased acuity Pain level Normal acuity Physiological Needs Increased acuity Sensorium Needs Normal acuity

Aminiah Hussain Room 301 Aminiah Hussain, 22-year-old Muslim female, G1 T0 P0 A0 L0, 39 5/7 weeks gestation. NKDA. Pregnancy uncomplicated. Woke up early morning feeling wet; wasn't sure if leaking urine or membranes ruptured. Has continued to stay wet and needed to wear a pad for the last 4 hours. No contractions or vaginal bleeding. Her husband, Mohammad, is with her. He is attending his first year of medical school at the University and both are in the United States on VISAs. He called the obstetrics office and the certified nurse midwife told them to come to the hospital for evaluation and possible induction of labor. Aminiah looks to her husband to answer questions. He reads English fluently but both Aminiah and her husband struggle to speak and understand English conversation. Both appear nervous and have a lot of questions about an induction.

Educational Needs Increased acuity Fall Risk Increased acuity Health change Increased acuity Pain level Normal acuity Physiological Needs Increased acuity Sensorium Needs Normal acuity

Carly Madison Room 302 Carly Madison, 30 y/o G1P0 who was admitted 4 hours ago in labor. Her cervical exam on admit revealed: 4 cm, 70%, fetal vertex at -1, slight bloody show, leaking membranes. She doesn't remember when the leaking began. Contractions on admit were q 5 minutes x 45 seconds. Mrs. Madison reported a pain level at 4/10. She and her husband have been to a Lamaze Prepared Childbirth series and their Birth Plan includes the desire for a non-medicated labor and birth. She and her husband have been doing Slow-Chest breathing and conscious relaxation techniques since admission. She is NPO other than ice chips; she has no IV at this point. Vital signs - BP 124/70, P 80, R 20, FHR is reassuring with a 136 BPM baseline with moderate variability no decelerations and +accelerations (Category 1). She is ambulating in her room with a portable maternal-fetal monitor applied. She puts her call light on and ask to see a nurse stating, "how much longer is this going to be? I am getting really tired."

Educational Needs Increased acuity Fall Risk Increased acuity Health change Normal acuity Pain level Increased acuity Physiological Needs Increased acuity Sensorium Needs Normal acuity

Jenny Smith Room 306 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 Needs Increased acuity Jenny will need education regarding dealing with the loss both mentally and physically. Fall Risk Increased acuity She may be at increased fall risk related to bleeding, pain, and pain medication. Health change Increased acuity She needs to be monitored for hemorrhage from the vaginal bleeding. Pain level Increased acuity The client rates their pain at 7/10. Physiological Needs Increased acuity Client is grieving a loss and expresses concern about herself and others coping. Sensorium Needs Normal acuity No issues reported here.

Kesha Jackson Room 303 Kesha Jackson, Patient is a G1P0, gestational age of 33.1. She came in complaining of contractions for 2 hours that are now every 5 mins. She is unsure about rupture of membranes, denying vaginal bleeding and recent intercourse. She states the baby is active. She rates her pain an 8/10. Her current vital signs are 98.1 F, 36.7 C, 92 BPM, 16 breaths/min, 122/64 mmHg, 99% on room air. The fetal heart rate is 135 baseline but is not yet reactive. Cervical exam reveals that she is not dilated or effaced, and the baby's head is not engaged in the pelvis. She has no medical history and NKA. In obtaining her history, it was learned that she is 15 years old, currently homeless, and has been staying with various friends. She does have some supplies including diapers, wipes, and some clothing that she received from a friend. She expresses the desire to take her baby home with her. She is receptive to teaching and assistance she just has been unsure of how to obtain it. She came to the OB triage via a bus.

Educational Needs Increased acuity Status Assessment reports Kesha will need a lot of education regarding preterm labor precautions, resources for assistance, and caring for her baby once it arrives Fall Risk Increased acuity Status Assessment reports Client is at increased of fall due to changing center of gravity and balance. Health Change Increased acuity Status Assessment reports in addition to the pregnancy, there are now additional health issues due to the preterm labor. Pain Level Increased acuity Status Assessment reports she rates her pain an 8/10 Psychological Needs Increased acuity Status Assessment reports Kesha is homeless, is pregnant, is a teen with developing coping mechanisms, and has a lack of a consistent support system. Sensorium Normal acuity Status Assessment reports no issues reported here.

Miranda Johnson Room 305 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 Needs Increased acuity Status report indicates patients last pregnancy was 10 years ago. Every pregnancy and labor are different therefore remedial labor and delivery education would beneficial. Patient also has mild scoliosis and weighs 250 pounds which could increase the difficulty of epidural insertion. Proper positioning and breathing techniques during the epidural procedure may lead to decreased difficulty of epidural insertion. Fall Risk Increased acuity Related to pregnancy and changes in balance and center of gravity. Health change Increased acuity Related to active labor and change in health status. Pain level Increased acuity Related to increased pain level of 7-8 out of 10. Physiological Needs Increased acuity Related to active labor, increased pain, and desire for epidural. Sensorium Needs Normal acuity No indication.

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:

Encourage vocalization of fear and concerns. Cluster nursing care activities as much as possible, such as medication administration, assessments, and vital signs. Offer diversional activities: watching TV, reading, crossword puzzles, small needlecraft activities. Request family to bring articles from home to "decorate" hospital room. Teach conscious relaxation and breathing techniques. Provide comfort measures such as back rubs, position changes, and aromatherapy.

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:

Establish therapeutic communication; review prenatal history with woman and events leading her to present to triage. Assess vital signs, including temperature. Perform Leopold's Maneuver. Apply external tocodynamometer and fetal transducer and palpate fundus to assess for contractions. Using a sterile gloved hand, test fluid leaking from vagina with Nitrazine paper.

Cindy Mason Scenario 5 Mrs. Mason has an uncomplicated, spontaneous vaginal delivery of an 8 pound baby girl. Mom and Dad are overjoyed and admiring their new baby girl. Placenta was delivered spontaneously. No vaginal or perineal lacerations were identified. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Perform an Apgar Score on infant at 1 and 5 minutes of birth. Place the infant in skin to skin contact with mother. Reassess maternal vital signs. Reassess uterine fundus for tone and location, if boggy massage till firm. Reassess lochia for amount and color; note any clots or odor.

Sarah Lane Scenario 3 After 10 minutes, no fetal movement or FHR accelerations are recorded on the monitor tracing. FHR baseline rate is 134 BPM with moderate variability. Mrs. Lane states she has "twinges" but unsure of fetal movement. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Readjust woman's position to opposite side, ensuring lateral tilt and provide ice chips or small amount of po fluids. Reassess maternal vital signs. Palpate for fetal movement. Adjust tocodynamometer and transducer. Confirm patient understanding of procedure, reassuring patient of fetal status.

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:

Perform Non-Stress Test (NST) now and bi-weekly BPP and every shift; teach woman to do Daily Fetal Movement Counts (DFMCs). Administer Betamethasone 12 mg IM for two doses 24 hours apart. Administer a broad-spectrum antibiotic (e.g., ampicillin, erythromycin) and continue for 7 days. Request neonatologist to visit patient. Assess results of daily CBC.

Ms. Susie Smith Scenario 4 Thirty (30) minutes later the monitor tracing reveals three (3) contractions in a 10-minute period lasting 50 seconds, FHR baseline is 130 bpm, moderate variability, and absence of decelerations with contractions. Ms. Smith reports feeling mild discomfort with contractions. Vaginal bleeding is absent, no leaking of fluid per vagina. Vital signs: BP 140/80 mmHg, P. 76 bpm., R. 20 breaths/minute. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Palpate fundus for resting tone and contraction intensity. Collaborate with healthcare provider on CST interpretation. Discontinue oxytocin infusion. Educate client on test results. Document assessment and test results.

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:

Maintain efficient, timely and continual factual and accurate documentation. Thoroughly document factual and accurate information. Discuss patient load with charge nurse. Always sign out when charting on a patient. NEVER ASSUME ANYTHING your care or the care of others.

Carly Madison Scenario 1 You enter the patient's room. After washing and gloving hands, you identify yourself and the patient, Mrs. Carly Madison. She appears anxious, has switched to shallow-chest breathing and is now sitting in the rocking chair. She says she hasn't had a cervical exam since she was admitted and is anxious to see if she has progressed any. Her Healthcare Provider arrives to examine her and states he may perform an amniotomy (AROM). SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Offer support and explain to the woman what will be done, assisting her to a lithotomy position with slight lateral tilt. Assess the FHR before procedure to obtain a baseline reading. Place a clean, dry pad under the woman's buttocks to absorb fluid. Assist the healthcare provider who is performing exam by opening sterile gloves, lubricant and sterile amniotomy hook. Reassess the FHR and document assessment; assess and record the color, consistency ad odor of the amniotic fluid.

Renee Wilson 26 y/o G1P0 admitted four hours ago to the Birthing Center. She has had an uncomplicated pregnancy, but her obstetrician has expressed the concern about needing a c-section because of the anticipation of a large baby. Her last ultrasound estimated fetal weight at 9 lbs. 6 oz. She and her husband have attended Lamaze Prepared Childbirth Classes and their Birth Plan includes the desire to have an unmedicated labor and vaginal birth. She also desires skin to skin contact with her baby at birth and breastfeeding. Admit assessment findings: Sterile vaginal exam (SVE) - 4 cm, 80% effaced, and fetal vertex at a -2 station with intact membranes, slight bloody show. BP 110/70 mmHg, P. 88 beats/minute, R 24 breaths/minute; T 98.8 F. 37.1 C. FHR 150 baseline with moderate variability + accelerations, absent decelerations (Category 1). Contractions are occurring every 2 minutes, lasting 60 seconds with moderate intensity per palpation. Portable tocodynamometer and fetal ultrasound transducer are in place. She is using shallow-chest breathing and conscious relaxation techniques and is ambulating in her room. She rates her pain at 5/10. She tells you that she will feel like a failure if she can't deliver vaginally.

Physiological Acute Pain Anxiety Imapired mobility Impaired patterns of elimination Infection, Risk for Safety Deficient Knowledge Fall, Risk for Impaired maternal newborn bonding, Risk for Risk for fetal injury Risk for Ineffective Coping Risk for Situational Self Esteem

Carly Madison 30 y/o G1P0 who was admitted 4 hours ago in labor. Her cervical exam on admit revealed: 4 cm, 70%, fetal vertex at -1, slight bloody show, leaking membranes. She doesn't remember when the leaking began. Contractions on admit were q 5 minutes x 45 seconds. Mrs. Madison reported a pain level at 4/10. She and her husband have been to a Lamaze Prepared Childbirth series and their Birth Plan includes the desire for a non-medicated labor and birth. She and her husband have been doing Slow-Chest breathing and conscious relaxation techniques since admission. She is NPO other than ice chips; she has no IV at this point. Vital signs - BP 124/70, P 80, R 20, FHR is reassuring with a 136 BPM baseline with moderate variability no decelerations and +accelerations (Category 1). She is ambulating in her room with a portable maternal-fetal monitor applied. She puts her call light on and ask to see a nurse stating, "how much longer is this going to be? I am getting really tired."

Physiological Acute Pain Anxiety Related to Labor and Birthing Process Fatigue Related to Energy Expenditure Required for Labor and Coping Skills Impaired Comfort Risk for Fluid Volume Deficit Safety Deficient Knowledge Risk for Maternal Infection

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.

Physiological Anxiety Infection, risk for Safety Deficient knowledge Fall, risk for Risk for injury, maternal/fetal

Sarah Lane Mrs. Sarah Lane is a 25 y/o G2P0 who is at 42 weeks gestation. Estimated fetal weight is 4000 Gm. She presents to the Maternal-Fetal Medicine Clinic today for a Non-Stress Test (NST). Her first pregnancy ended in a miscarriage at 10 weeks gestation. Her husband has accompanied her to every prenatal visit; they both appear anxious regarding the test and the health of their baby.

Physiological Anxiety Risk for Fetal Injury Risk for Impaired Fetal Gas Exchange Safety Deficient knowledge Fall, Risk for Risk for Ineffective Individual Coping Risk for Maternal Injury

Ms. Susie Smith 33 y/o G2P0 at 42 weeks' gestation. She is single with a limited support system. She has just completed a Non-Stress Test (NST) which was interpreted as being Non-Reactive. Her obstetrician has now ordered an Oxytocin-Stimulated Contraction Stress Test (CST). Fetal membranes are intact. Ms. Smith also has a history of hypertension and a previous pregnancy loss at 18 weeks' gestation. She is crying and states "I can't lose another baby". External tocodynamometer and fetal ultrasound transducer remain in place from the NST.

Physiological Anxiety Risk for Impaired Fetal Gas Exchange Safety Deficient Knowledge Fall, Risk for Maternal Injury, Risk for Risk for Ineffective Coping

Cindy Mason 28 y/o G2P1 at 40 weeks gestation. She and her husband present to OB Triage with complaint of early labor. Her prenatal history indicates an uncomplicated first pregnancy with a spontaneous vaginal delivery. Her current pregnancy has also been uncomplicated with no risk factors identified. She and her husband have attended Lamaze Prepared Childbirth classes and their Birth Plan indicates a desire for an unmedicated labor and birth and breastfeeding. Mrs. Mason states her contractions are occurring every 4 minutes and lasting 60 seconds. She is using slow-chest breathing and rates her pain at 4/10. She also reports leaking clear fluid from her vagina. She believes the leaking began about two hours ago.

Physiological Fatigue Related to Energy Expenditure Required for Labor and Coping Skills, risk for Impaired Comfort Infection, Risk Risk for Impaired Urinary Elimination Safety Deficient knowledge

Aminiah Hussain 22-year-old Muslim female, G1 T0 P0 A0 L0, 39 5/7 weeks gestation. NKDA. Pregnancy uncomplicated. Woke up early morning feeling wet; wasn't sure if leaking urine or membranes ruptured. Has continued to stay wet and needed to wear a pad for the last 4 hours. No contractions or vaginal bleeding. Her husband, Mohammad, is with her. He is attending his first year of medical school at the University and both are in the United States on VISAs. He called the obstetrics office and the certified nurse midwife told them to come to the hospital for evaluation and possible induction of labor. Aminiah looks to her husband to answer questions. He reads English fluently but both Aminiah and her husband struggle to speak and understand English conversation. Both appear nervous and have a lot of questions about an induction.

Physiological Injury, risk for Safety Fall Risk Injury, risk for fetal Injury, risk for maternal Love and Belonging Anxiety Deficient Knowledge Spiritual Distress, risk for

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 Risk for Impaired Urinary Elimination Risk for Maternal Injury Safety Deficient knowledge Fall, Risk for

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.

Physiological acute pain altered family processes (anxiety&bleeding)grieving infection, risk for Safety Fall, risk knowledge deficit

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:

Place bed in Trendelenburg position. Discuss plan of care with patient; answer questions honestly, especially concerning SROM and implications for preterm labor and birth. Assess support systems available to woman. Apply sequential compression device (SCD) boots and connect to machine. Begin Intake and Output (I&O) chart and document every shift.

Sarah Lane Scenario 2 Mrs. Lane has indicated understanding of NST procedure. Her husband remains at her side and both are ready to begin Non-Stress test, NST. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Position patient in reclining chair (or semi-Fowlers position) with left lateral tilt. Perform Leopold's Maneuver. Apply doppler transducer to abdomen over location of fetal back. Apply tocodynamometer to uterine fundus. Teach patient to use handheld event marker connected to monitor

Renee Workman Scenario 3 The healthcare provider orders labs including a 24-hour urine for protein and creatinine. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Post signs and in the EHR/plan of care regarding the 24-hour urine collection. Ask the client to void and discard the urine. Place the urine in a special container or on ice. Collect all urine in the next 24 hours. Ask the client to void and save the urine. Label and send the urine specimen to the lab.

Cindy Mason Scenario 3 Two hours later Mrs. Mason is using shallow-chest breathing to cope with contractions. Assessment findings: BP 120/80 mmHg. P. 90 R 26; contractions are every two minutes, lasting 65 seconds, strong to palpation; moderate bloody show with clear amniotic fluid; pain rated at 6/10, c/o increasing back pain. Sterile vaginal exam: 8 cm, 100%, 0 station. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Praise her efforts and tell her that she is almost ready to deliver Encourage her to void at least every two hours Assist her with peri-care and change underpads as needed Teach husband how to apply counter-pressure to woman's back during contractions while sitting on birthing ball. Continue to provide comfort measures and minimize distractions in room

Aminiah Hussain Scenario 3 Dr. Hussain states he will be present for decision making but that the certified nurse midwife that Aminah has been seeing throughout the pregnancy, Beth, and the staff nurse will support Aminah during the labor and birth process. Only female health care providers will be allowed into the room. Privacy and modesty are very important to both of them. They wish to allow Allah to provide for comfort and not have any medications. As father, he wishes to whisper prayers into the baby's ear shortly after birth and pin a verse from the Qur'an to the newborn's clothing for protection. Aminah will breastfeed the baby for 2 years. Prior to the first feeding, she will need to rub a small piece of softened date onto the baby's palate. Aminah's sister will be traveling to the US to assist with the care of the baby as he will be returning to his residency program. They will use social media to contact their family after the baby's birth once both mother and baby have been cleaned up and fed. The nurse uses the answers to the cultural and spiritual assessment to blend with labor and birth protocols and develop a plan of care. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Provide written information and instructions about the induction of labor protocols to the husband. Allow the health care provider to explain the process and answer questions. Allow the client's husband to sign the consent on her behalf. Female health care providers only. Keep client covered as much as possible and use non-pharmacological comfort measures. Minimize vaginal exams for both comfort and to decrease risk of infection. After birth, dry the newborn and allow the father to hold the baby briefly before placing skin to skin with mother. Assess 1-minute Apgar score while in father's arms and 5-minute score on mother's abdomen- unless there is need for neonatal resuscitation. Allow mother to rub a soft date on newborn's palate prior to feeding. Assist the newborn to breastfeed within the first hour.

Renee Wilson Scenario 3 Oxytocin augmentation was ordered by the healthcare provider and begun at 2 mu/min, with an order to increase by 1-2 mu/min every 30 minutes based on the response of the woman and fetus and progress of labor. Mrs. Wilson has been laboring for 8 hours now and is 6 cm, 80%, but still at a -2 station. Vital signs are stable; T 98.8oF, FHR remains a Category 1 with baseline at 150 bpm, moderate variability and + accelerations. Mrs. Wilson is complaining of back pain and tells you she is getting tired and asks for advice on coping. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Reassess maternal and fetal status every 15 minutes and with each dose change of oxytocin. Encourage her to void at least every two hours, assessing intake and output. Assist her with peri-care and change underpads as needed. Teach husband how to apply counter-pressure to woman's back during contractions while sitting on birthing ball. Continue to provide comfort measures and minimize distractions in room.

Maria Sanchez Scenario 2 Maria, Raul and her family have bottle fed Juan during the two days of the postpartum stay. Maria's grandmother brings her chicken and broccoli soup each day to bring "heat" to the "cold" state of postpartum and to promote milk flow for breastfeeding. A protective amulet has been placed around the newborn's ankle for protection. Both mother and newborn have progressed without complications. Prior to discharge Maria states, "My breasts are getting hard and uncomfortable. I hope I will be able to breast feed him after I get home. Can you help me?". SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Reassure Maria that engorgement is a common and temporary condition; lasts about 24 hours, caused by the milk coming in as well as increased blood supply and swelling. Instruct Maria to breastfeed Juan based on infant feeding cues Provide a breast pump and instruct Maria to use it after breastfeeding to soften the second breast if needed. Apply cold packs between feedings to relieve swelling; 15-20 minutes on and 45 minutes off. Ibuprofen 600 mg orally can be taken every 6 hours.

Carly Madison Scenario 2 The healthcare provider's exam reveals the cervix to still be 4 cm. dilated but now 100% effaced, and fetal vertex at a 0 station. There is a moderate amount bloody show; AROM yielded clear fluid. Contractions have not changed in frequency or intensity since admit. The healthcare provider discusses with the patient the potential to begin oxytocin if the amniotomy does not increase the contraction pattern and facilitate cervical change. The healthcare provider and the registered nurse discuss a plan for active labor management with the patient and her husband. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Reassure client that progress has been made; review plan with the woman and husband and assess understanding. Assist woman to restroom to empty her bladder. Encourage use of birthing ball Reassess fetal heart rate and contraction pattern every 30 minutes Document the updated plan of care in the electronic medical record

Carly Madison Scenario 3 Two hours later, the healthcare provider performs another vaginal exam. Assessment findings: Cervix 5 cm., 100%, 0 station; contractions are q 5 minutes, lasting 60 seconds, but intensity remains unchanged. FHR is evaluated as Category 1. The healthcare provider gives the nurse a verbal order to begin oxytocin (Pitocin) at 1 mu/minute, increasing by 1-2 mu/min every 30 minutes. A standard concentration of 500 mL Lactated Ringer's with 30 units oxytocin is used. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Reassure client that progress is being make; educate the woman and her husband on the reasons for augmentation and anticipated response to medication. Assess maternal vital signs and FHR immediately prior to initiating oxytocin and then every 15 minutes. Administer oxytocin intravenously through a secondary line connected to the main line at the proximal port (closest to patient) with an IV pump. Monitor contraction pattern and palpate uterine resting tone every 15 minutes and with every dose change. Document initiation of oxytocin and every increase, decrease or discontinuance.

Cindy Mason Scenario 1 After washing your hands, introduce yourself to the patient, Mrs. Cindy Mason, and her husband. You escort her to a triage bed and hand her a gown to change in to. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Review prenatal history with patient and Birth Plan. Obtain maternal vital signs. Perform Leopold's Maneuver. Apply fetal transducer and external tocodynamometer and palpate fundus during contractions. Perform a Sterile Vaginal Exam.

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:

Review prenatal record with patient. Confirm pregnancy complications, allergies, and orders for epidural. Witness signing of epidural informed consent by Anesthesiologist and patient AFTER preanesthetic evaluation. Initiate IV bolus per order in preparation of epidural procedure. Gather epidural medications to include Ephedrine, per Anesthesiologist orders, epidural tray, crash cart, nonrebreathing mask, O2 tubing, and suctioning equipment. Monitor patient BP, Pulse, O2 Sat, and FHR during epidural procedure according to established guidelines.

Kesha Jackson Patient is a G1P0, gestational age of 33.1. She came in complaining of contractions for 2 hours that are now every 5 mins. She is unsure about rupture of membranes, denying vaginal bleeding and recent intercourse. She states the baby is active. She rates her pain an 8/10. Her current vital signs are 98.1 F, 36.7 C, 92 BPM, 16 breaths/min, 122/64 mmHg, 99% on room air. The fetal heart rate is 135 baseline but is not yet reactive. Cervical exam reveals that she is not dilated or effaced, and the baby's head is not engaged in the pelvis. She has no medical history and NKA. In obtaining her history, it was learned that she is 15 years old, currently homeless, and has been staying with various friends. She does have some supplies including diapers, wipes, and some clothing that she received from a friend. She expresses the desire to take her baby home with her. She is receptive to teaching and assistance she just has been unsure of how to obtain it. She came to the OB triage via a bus.

Saftey Fall Risk Ineffective health maintenance Knowledge Deficit Psychological Impaired home maintenance Risk for impaired parenting Physiological Acute Pain Risk for nutritional imbalance

Maria Sanchez 20-year-old female, G1 P1 L1, 39 weeks gestation. Pregnancy uncomplicated. O+, Rubella immune, Group B Strep negative. NKDA. 12-hour 1st stage, 1 hour 2nd stage, 10 minute 3rd stage. Spontaneous vaginal delivery with 1st degree perineal laceration one hour ago. Vital signs stable; fundus firm, midline, at umbilicus; Lochia rubra moderate, no clots; Up to bathroom x1- 500 mL, no dysuria, instructed on peri-care; Legs still a little "tingly" but able to bear weight with assist X2. Pain level 3/10- ice to perineum with relief. Neonate male- Juan- 3500 g; Apgar 8 & 9; T 36.8 C, 98.2 F; AP 156 beats/minute, regular; R 52 breaths/minute, irregular. Skin-to-skin with mother for first hour. Beginning to show hunger cues. Their plan is do both breast and bottle feeding; "las dos cosas." Maria's husband Raul is a quiet presence. Her mother, grandmother, and older sister were Maria's support persons in labor. Maria and Raul are bilingual in English and Spanish. They were both born in the US- are Mexican Americans. Her mother speaks and understands more English than her grandmother does.

Saftey Fall Risk Injury, risk for maternal Physiological Acute Pain Ineffective breastfeeding, risk for Infection, risk for Love and Belonging Deficient Knowledge Readiness for Enhanced Parenting

Renee Workman Renee Workman, 35-year-old African American female, G2 T0 P0 A1 L0, 36 weeks gestation, history of In Vitro Fertilization with one failed implantation. Otherwise uncomplicated pregnancy. Reported decreased fetal movement today. BP of 144/92 in office. Weight up 2 kg in 2 weeks since last appointment. Urine +1 protein on dipstick. Mild headache and slightly blurry vision. No contractions, leaking of fluid or vaginal bleeding. Wife accompanies client.

Saftey Fall Risk Injury, risk for maternal Physiological Deficient Fluid Volume Injury, risk for fetal Injury, risk for maternal Love and Belonging Anxiety Health Maintenance

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:

Turn epidural pump off. Lower HOB, elevate foot of the bed, and reposition patient to left lateral position. Rapid infusion (bolus) of IV fluids. Apply nonrebreathing oxygen mask and set to 10L/minute per order. Consider administration of Ephedrine.

Jenny Smith Scenario 1 You enter the room and find Jenny alone in the room sitting in bed. She appears in no distress and asks that you leave her alone for now because she does not feel like talking. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Use therapeutic communication and express that you are here to listen if she wishes to talk. Assess her overall condition and vital signs if available. Respect her wish to be alone at this time and ask if there is anyone to call/reassure you will return. Ensure that call light in reach and leave the room. Document the conversation.

Kesha Jackson Scenario 5 Kesha is preparing for likely discharge. Kesha requires teaching on the warning signs of preterm labor, the importance of the second dose of steroids, and follow up with healthcare provider. She also needs additional education regarding her options, referrals, resources for assistance, childcare, etc. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:Use therapeutic communication techniques.

Use therapeutic communication techniques. Assess her cognitive level and readiness to learn. Discuss referral to social work/case management. Provide clear information along with printed material that she can take with her. Allow her to ask any questions that she may have after teaching is complete. Evaluate her understanding of the information provided using proven techniques such as teach-back or return demonstration.

Kesha Jackson Scenario 4 Upon entering Kesha's room, you notice that she seems upset. When questioned, she expresses concern about finding a place to stay and her ability to care for herself and the baby. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Use therapeutic communication.T Allow her to express her feelings and concerns. Ask open ended questions to further develop the conversation. Answer any questions openly and offer support. Document the conversation.

Ms. Susie Smith Scenario 5 After communicating with healthcare provider regarding CST results, you are preparing to discharge Ms. Smith. As the maternal/fetal monitor transducers are being removed, Ms. Smith tells you that she feels like she may have urinated on herself. Upon visual assessment of the perineum, you observe clear fluid leaking from her vagina onto the underpads. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Using a sterile gloved hand, test fluid leaking from vagina with Nitrazine paper. Reapply tocodynamometer and transducer to maternal abdomen. Maintain IV access with Lactated ringer's infusion. Notify healthcare provider of assessment findings and collaborate on plan of care. Reassure woman and educate on plan of care.

Sarah Lane Scenario 1 After reviewing the patient's prenatal history, you enter the patient's room, identifying yourself and the patient, Mrs. Sarah Lane, and greeting her husband. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Wash hands and apply non-sterile gloves. Review patient prenatal history with woman, confirming understanding of reasons for NST. Have woman empty bladder. Educate woman and husband on process of NST. Obtain maternal Vital Signs.

Maria Sanchez Scenario 1 The nurse enters Maria's room to begin the initial shift assessment. The neonate is bringing his hand to his mouth, sucking on his hand, and rooting on his mother's chest. The nurse points out the feeding readiness cues and asks if Maria would like assistance with breastfeeding. Maria's mother asks for a bottle of formula for the baby. She states the colostrum is "spoiled" and Maria will wait to breast feed when her milk comes in. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Wash hands and introduce self to the client and her husband. Ask client and her husband what they prefer to be called. Ask Maria if she agrees with her mother; if so, bring a bottle to the room for feeding the newborn. Ask permission prior to touching the client. Obtain her vital signs, perform a pain assessment and assessment of fundus, lochia, and perineum. Assess newborn vital signs and head-to-toe assessment.

Aminiah Hussain Scenario 1 After obtaining report, the nurse looks in the computer for Aminiah's prenatal record and lab reports. She is Blood type A+, Rubella immune, and GBS negative. The nurse enters Aminiah's room to begin the initial admission assessment. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Wash hands and introduce self to the client and her husband. Ask client and her husband what they prefer to be called. Ask if there is need for an interpreter or translator and any specific privacy needs during the assessment. Ask permission prior to touching the patient. Obtain her vital signs, fetal heart tones, and perform a pain assessment. Ask about time of rupture of membranes and observe color of fluid. Educate client about the status of the fetal heart tones.

Renee Workman Scenario 1 The nurse prepares to complete an initial assessment. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Wash hands/apply gloves. Introduce self and explain assessments to be completed. Apply electronic fetal monitor. Assess maternal vital signs- temperature, pulse, BP both arms. Auscultate heart and breath sounds. Assess for peripheral edema and reflexes.

Aminiah Hussain Scenario 2 The nurse completes an initial assessment. T 37 C, 98.6 F, P 80 bpm, regular; R 18 breaths/min., regular; BP 118/78 mmHg; 0/10 Pain. FHR 140, moderate variability, 2 accelerations to 155 in 20 minutes. No contractions on EFM. The client wishes to be called Aminiah and her husband prefers to be called Dr. Hussain. He doesn't think they need an interpreter but would like written information about the induction. Dr. Hussain states he will answer questions for his wife and sign any consent forms. Aminiah nods her head that this arrangement is "OK" with her. The nurse now continues with a cultural and spiritual assessment and selects questions to be asked during the assessment as nursing actions. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED:

Who do you want to be with you in labor? What can your labor support person do to help you be most comfortable during labor? What actions are important for you and your family immediately after the baby's birth? What do you expect from the nurses caring for you during the postpartum period? How will other members of your family participate in the care of you and the new baby once you go home?