BSN 346 Shadow Health Non-Reassuring Fetal Status Case Review
and Notes | 100% Score | Complete Solutions | 2026
Vitals
Vitals 0600 0700
Temp (<38° C) 36.7 C 36.7
BP (<120/80) 117/72 120/72
HR (60-100) 88 bpm 88
RR (12-20) 18 18
O2 Sat (>94%) 98% 98
Pain Scale 5/10 5
Documentation / Electronic Health Record
Subjective Notes
, Student Documentation Model Documentation
Luna Morales is a 35-year-old Puerto Rican woman who
experienced non-reassuring fetal status. At my last check,
she was still in the early phase of labor and the fetal heart
rate had returned to normal. Ms. Morales reported
Subjective contraction pain in her upper abdomen, rating it 5/10 on a
Patient is multigravida with two pain scale. Her contractions last for one minute and occur
children living at home. Patient is every five minutes. During her pregnancy, Ms. Morales did
full term and would like to have not experience any complications with her health or the
this baby naturally without any baby’s. The NRFS was her only complication. She has not
pain medication. received any medications and does not wish to, pending her
desire to have a natural vaginal birth. Her birth plan includes
use of natural pain management strategies including yoga
breathing, position changes, and smelling essential oils
diffused through her bracelet.
Objective Notes
Student Documentation Model Documentation
Patient had no visible abnormalities. Slight edema is
Objective present in the right and left ankles and feet, symmetric
Patient has normal vitals. She is bilaterally. Breath sounds were clear in all areas with no
healthy and has no drug allergies. adventitious sounds. Heart sounds had regular rate and
She is 3cm dilated and ready to rhythm, with S1 and S2 audible and no extra sounds
have the baby. present. Vitals are normal. Fetal presentation is vertex,
fetus position is posterior.
Care Plan : 5 of 8 (62.5%)
Nursing Diagnosis
1 out of 1
and Notes | 100% Score | Complete Solutions | 2026
Vitals
Vitals 0600 0700
Temp (<38° C) 36.7 C 36.7
BP (<120/80) 117/72 120/72
HR (60-100) 88 bpm 88
RR (12-20) 18 18
O2 Sat (>94%) 98% 98
Pain Scale 5/10 5
Documentation / Electronic Health Record
Subjective Notes
, Student Documentation Model Documentation
Luna Morales is a 35-year-old Puerto Rican woman who
experienced non-reassuring fetal status. At my last check,
she was still in the early phase of labor and the fetal heart
rate had returned to normal. Ms. Morales reported
Subjective contraction pain in her upper abdomen, rating it 5/10 on a
Patient is multigravida with two pain scale. Her contractions last for one minute and occur
children living at home. Patient is every five minutes. During her pregnancy, Ms. Morales did
full term and would like to have not experience any complications with her health or the
this baby naturally without any baby’s. The NRFS was her only complication. She has not
pain medication. received any medications and does not wish to, pending her
desire to have a natural vaginal birth. Her birth plan includes
use of natural pain management strategies including yoga
breathing, position changes, and smelling essential oils
diffused through her bracelet.
Objective Notes
Student Documentation Model Documentation
Patient had no visible abnormalities. Slight edema is
Objective present in the right and left ankles and feet, symmetric
Patient has normal vitals. She is bilaterally. Breath sounds were clear in all areas with no
healthy and has no drug allergies. adventitious sounds. Heart sounds had regular rate and
She is 3cm dilated and ready to rhythm, with S1 and S2 audible and no extra sounds
have the baby. present. Vitals are normal. Fetal presentation is vertex,
fetus position is posterior.
Care Plan : 5 of 8 (62.5%)
Nursing Diagnosis
1 out of 1
