Fetal Distress/Cesarean Section
UNFOLDING Reasoning
Luella Jones, 25 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
Reproduction
Clinical Judgment
Collaboration
Patient Education
Communication
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
Management of Care 17-23%
Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity
Basic Care and Comfort 6-12%
Pharmacological and Parenteral Therapies 12-18%
Reduction of Risk Potential 9-15%
Physiological Adaptation 11-17%
, UNFOLDING Reasoning Case Study
History of Present Problem:
Luella Jones is a 25-year-old female patient G1P0 who is currently 40 3/7 weeks gestation. She is admitted to the
hospital to be induced for being post-date. She is positive for Group Beta streptococcus and receiving IV antibiotics per
protocol. She is 65 inches (162.5 cm). Her pre-pregnancy weight was 115 pounds (52.3 kg). She gained 15 pounds (6.8
kg) during this pregnancy. She just had spontaneous rupture of membranes with a moderate amount of thick meconium
fluid. The nurse performed a vaginal check, and her cervix is dilated to 4 cm, 8 percent effaced and -1 station. Pitocin is
infusing at 6 mU/minute intravenously.
Personal/Social History:
Luella lives alone and is no longer involved with the father of her baby. Her family support is limited to her older sister.
She smokes one pack of cigarettes a day and has not had a job for over a year and states money is tight. She admits to not
eating very healthy during the pregnancy because it is easier to grab chips and pop than cook. She missed a few of her
prenatal visits due to transportation issues and did not attend any prenatal classes. Her sister is present as her support
person during labor and delivery.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
40 3/7 weeks gestation Postdates can put her at higher risk for cesarean section and meconium
aspiration for baby
She gained 15 pounds during the pregnancy At risk for Intrauterine Growth Restriction (IUGR), malnourished fetus
and is 65 inches (162.5 cm); pre-pregnancy
weight was 115 pounds.
She is Group Beta Strep (GBS) Positive and Baby at risk to contract the GBS infection
currently receiving IV antibiotics per
protocol.
She just had spontaneous rupture of Clinical RED FLAG! Infant is at risk for meconium aspiration
membranes with a moderate amount of thick
meconium fluid.
Cervix is dilated to 4 cm, 80% effaced, -1 Labor is progressing as expected at this point
station
RELEVANT Data from Social History: Clinical Significance:
Luella lives alone and is no longer involved Having little support can put her at risk for added stress after delivery
with the father of the baby. She states she and for postpartum depression
doesn’t have much family support besides
her sister.
She smokes one pack of cigarettes a day. Smoking can cause lower birth weight in the infant. Also increases risk
for respiratory distress
She has not had a job for over a year now and Decrease financial means to support herself and baby
states money is tight.
She admits to not eating very healthy during Infant at risk for being malnourished
the pregnancy because it is easier just to grab
some chips and pop than to cook anything.
She missed a few of her prenatal visits due to
UNFOLDING Reasoning
Luella Jones, 25 years old
Primary Concept
Perfusion
Interrelated Concepts (In order of emphasis)
Reproduction
Clinical Judgment
Collaboration
Patient Education
Communication
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
Management of Care 17-23%
Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity
Basic Care and Comfort 6-12%
Pharmacological and Parenteral Therapies 12-18%
Reduction of Risk Potential 9-15%
Physiological Adaptation 11-17%
, UNFOLDING Reasoning Case Study
History of Present Problem:
Luella Jones is a 25-year-old female patient G1P0 who is currently 40 3/7 weeks gestation. She is admitted to the
hospital to be induced for being post-date. She is positive for Group Beta streptococcus and receiving IV antibiotics per
protocol. She is 65 inches (162.5 cm). Her pre-pregnancy weight was 115 pounds (52.3 kg). She gained 15 pounds (6.8
kg) during this pregnancy. She just had spontaneous rupture of membranes with a moderate amount of thick meconium
fluid. The nurse performed a vaginal check, and her cervix is dilated to 4 cm, 8 percent effaced and -1 station. Pitocin is
infusing at 6 mU/minute intravenously.
Personal/Social History:
Luella lives alone and is no longer involved with the father of her baby. Her family support is limited to her older sister.
She smokes one pack of cigarettes a day and has not had a job for over a year and states money is tight. She admits to not
eating very healthy during the pregnancy because it is easier to grab chips and pop than cook. She missed a few of her
prenatal visits due to transportation issues and did not attend any prenatal classes. Her sister is present as her support
person during labor and delivery.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
RELEVANT Data from Present Problem: Clinical Significance:
40 3/7 weeks gestation Postdates can put her at higher risk for cesarean section and meconium
aspiration for baby
She gained 15 pounds during the pregnancy At risk for Intrauterine Growth Restriction (IUGR), malnourished fetus
and is 65 inches (162.5 cm); pre-pregnancy
weight was 115 pounds.
She is Group Beta Strep (GBS) Positive and Baby at risk to contract the GBS infection
currently receiving IV antibiotics per
protocol.
She just had spontaneous rupture of Clinical RED FLAG! Infant is at risk for meconium aspiration
membranes with a moderate amount of thick
meconium fluid.
Cervix is dilated to 4 cm, 80% effaced, -1 Labor is progressing as expected at this point
station
RELEVANT Data from Social History: Clinical Significance:
Luella lives alone and is no longer involved Having little support can put her at risk for added stress after delivery
with the father of the baby. She states she and for postpartum depression
doesn’t have much family support besides
her sister.
She smokes one pack of cigarettes a day. Smoking can cause lower birth weight in the infant. Also increases risk
for respiratory distress
She has not had a job for over a year now and Decrease financial means to support herself and baby
states money is tight.
She admits to not eating very healthy during Infant at risk for being malnourished
the pregnancy because it is easier just to grab
some chips and pop than to cook anything.
She missed a few of her prenatal visits due to
