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Caseanalysis

The document provides a case study simulation of nursing care for a laboring mother. It describes a 27-year old pregnant woman who is 40 weeks and 2 days pregnant presenting with contractions every 2 minutes. Upon examination, her cervix is dilated to 7 cm and contractions are 1 minute apart. Vital signs and fetal heart rate are monitored. The baby's position and station are noted. The nurse monitors for an hour and notes the baby has descended further. Staff is ready for delivery when the doctor arrives. The document also provides a second case of a 23-year old woman in her first pregnancy admitted in active labor at 39 weeks. Her cervix is dilated to 7 cm upon admission. She is apprehensive about coping

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Chrislyn Dian Pene
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819 views2 pages

Caseanalysis

The document provides a case study simulation of nursing care for a laboring mother. It describes a 27-year old pregnant woman who is 40 weeks and 2 days pregnant presenting with contractions every 2 minutes. Upon examination, her cervix is dilated to 7 cm and contractions are 1 minute apart. Vital signs and fetal heart rate are monitored. The baby's position and station are noted. The nurse monitors for an hour and notes the baby has descended further. Staff is ready for delivery when the doctor arrives. The document also provides a second case of a 23-year old woman in her first pregnancy admitted in active labor at 39 weeks. Her cervix is dilated to 7 cm upon admission. She is apprehensive about coping

Uploaded by

Chrislyn Dian Pene
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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CHRISLYN DIAN PENE BSN2-OREM

Below is a case study simulation of nursing care of a mother about to deliver. Immerse yourself in the
given scenario and answer the given questions below. Output should be submitted as pdf file on or
before the given time limit and be uploaded in the designated database for this particular activity.

Activity # 1
CLINICAL SIMULATION:
Labor Progression Case Study
CLIENT PROFILE
A 27-year-old female who is 40 weeks and 2 days pregnant, with contractions occurring once every 10
minutes. The patient is checked in, vital signs are normal, fetal heart tones are normal and the mother
and father to-be are settled into their room for the night. It is 4 am and the call light goes off. The
patient reports she is feeling contractions every 2 minutes now and she thinks her water may have
broken.
The nurse is prepared for the delivery and is talking the mother through her breathing, the cervix is
dilated to 7 cm and the contractions are now 1 minute apart.
Vital signs are as follows:
RR - 30 bpm
HR - 125 bpm
BP - 110/67 mmHg
Fetal HR - 133 bpm
The nurse checks the presentation of the baby and notes the baby head is in the vertex position, the
bottom is in the frank position and baby is in the -1 station. The nurse monitors mom and baby for
another hour and upon re-checking the position of the baby the nurse notes that the baby is now +1
station and the cardinal movement is descent and flexion. The doctor has been brought to bedside and
staff is ready for delivery. As the baby is delivered the occiput is facing the right side of the pelvis and
towards the front.

1.How can the nurse find out if the patient’s water has broken?
ANSWER: Check for fluid exiting the vagina, use a Nitrazine test to evaluate if it is amniotic fluid
or urine or vaginal discharge.

2. What color should the test be if the membranes have ruptured?


ANSWER: Blue/Purple

3. What is the most important thing to have ready at this time?


ANSWER: An infant warmer, if delivery happens the infant needs to be cleaned and placed under the
infant warmer while an APGR test is performed.

4. What station number means the baby is starting to come out?


ANSWER: Positive numbers indicate the baby is starting to exit the pelvis.

5. What cardinal movement is the baby currently in?


ANSWER: Engagement, also called lighting or dropping.

6. What does the nurse need to make sure has happened?


ANSWER: The doctor has been brought to bedside and staff is ready for delivery.
7. What position is the newborn in at delivery?
ANSWER: Right Occiput Anterior (ROA)

Activity #2
You are about to take care a patient who is in active phase of first stage of labor. Upon admission, you
need to equip yourself with a concrete individualized nursing care plan that will serve as your guide in
the course of management for your patient. After reading and immersing yourself in the given case you
are asked by your Unit Head Nurse to submit your plan of care of the newly admitted patient.
Formulate 3 individualized nursing care plan containing a nursing diagnosis applicable to the given case,
formulate your desired outcome/goal and list down individualized nursing interventions for each
outcome or goal.
Candice, a 23-year-old gravida 1, para 0 (G1,P0) is admitted to the labor and birth suite at
39 weeks’ gestation having contractions of moderate intensity every 5 to 6 minutes. A vaginal exam
reveals her cervix is 80% effaced and 5 cm dilated. The presenting part (vertex)
is at 0 station and her membranes ruptured spontaneously 4 hours ago at home. She is admitted and an
IV is started for hydration and vascular access. An external fetal monitor
is applied. FHR is 140 bpm and regular. Her partner is present at her bedside. Candice is
now in the active phase of the first stage of labor, and her assessment findings are as follows: cervix
dilated 7 cm, 80% effaced; moderate to strong contractions occurring regularly, every 3 to 5 minutes,
lasting 45 to 60 seconds; at 0 station on pelvic exam; FHR auscultated loudest below umbilicus at 140
bpm; vaginal show—pink or bloody vaginal mucus; currently apprehensive, inwardly focused, with
increased dependency; voicing concern about ability
to cope with pain; limited ability to follow directions.

ANSWER:
Nursing Diagnosis Desired Outcome/Goal Nursing Interventions

Acute Pain related to tissue 1.Patient will identify/use 1.Encourage the patient to slow
dilation and possibly evidenced techniques to control pain. her breathing and taken shallow
by muscle tension. 2.Patient will report discomfort breath.
is minimized, as evidenced by 2.Offer a paper bag for the
statements of pain relief, pain client where she can breathe
rating 3 on pain rating scale. into.
3.Patient will be free of 3.The husband is encourage to
untoward side effects if stay with the patient to keep
analgesia or anesthetic agents her at ease.
are administered.

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