Maternity Case 2: Brenda Patton
Documentation Assignments
1. Document your initial assessment data of Ms. Patton, including uterine activity (frequency and
duration), fetal heart rate (FHR) activity (baseline FHR, long-term variability, accelerations, and
decelerations), vaginal discharge, and maternal vital signs.
Brenda Patton is an 18-year-old Caucasian female, G1P0 at 38 2/7 weeks of gestation admitted to the
labor and birthing unit for labor assessment. The patient states that her water may have broken
earlier this morning and she thinks she is in labor. AmniSure was positive. Vaginal exam reveals 50%
m
er as
effacement of cervix, cervical dilation 4 cm, and fetus at -2 station. The lab report indicates that the
co
patient's group B strep vaginorectal culture taken at 36 weeks was positive.
eH w
Patient status - Heart rate: 89. Pulse: Present. Blood pressure: 120/71 mmHg. Respiration: 20. Conscious
o.
rs e
state: Appropriate. SpO2: 97%. Temp: 37 C. EFM: Baseline with occasional accelerations. Fetal heart
ou urc
rate: 141.
2. Document the medication(s) that you administered.
o
Penicillin 5 million IU IVPB
aC s
vi y re
3. Document Ms. Patton’s pain during labor (severity during contractions, location, quality, interventions
taken, and response to interventions) and the measures that were taken to promote her desire for a
natural birth.
ed d
Uterus tone was soft between contractions. Regular contractions with moderate intensity had started.
ar stu
Contractions were approximately 4 minutes apart and lasting 50 seconds.
Pain: 2 between contractions., Location: everywhere
is
Th
4. Document your handoff report in the situation-background-assessment-recommendation (SBAR)
format to communicate what further care Ms. Patton needs.
sh
S: Brenda Patton is an 18-year-old Caucasian female, G1P0 at 38 2/7 weeks of gestation
admitted to the labor and birthing unit for labor assessment. The patient states that her
water may have broken earlier this morning and she thinks she is in labor. AmniSure
was positive. Vaginal exam reveals 50% effacement of cervix, cervical dilation 4 cm,
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
This study source was downloaded by 100000796901680 from CourseHero.com on 04-01-2021 15:55:30 GMT -05:00
https://www.coursehero.com/file/53301415/MaternityCase2-BPdocx/
Documentation Assignments
1. Document your initial assessment data of Ms. Patton, including uterine activity (frequency and
duration), fetal heart rate (FHR) activity (baseline FHR, long-term variability, accelerations, and
decelerations), vaginal discharge, and maternal vital signs.
Brenda Patton is an 18-year-old Caucasian female, G1P0 at 38 2/7 weeks of gestation admitted to the
labor and birthing unit for labor assessment. The patient states that her water may have broken
earlier this morning and she thinks she is in labor. AmniSure was positive. Vaginal exam reveals 50%
m
er as
effacement of cervix, cervical dilation 4 cm, and fetus at -2 station. The lab report indicates that the
co
patient's group B strep vaginorectal culture taken at 36 weeks was positive.
eH w
Patient status - Heart rate: 89. Pulse: Present. Blood pressure: 120/71 mmHg. Respiration: 20. Conscious
o.
rs e
state: Appropriate. SpO2: 97%. Temp: 37 C. EFM: Baseline with occasional accelerations. Fetal heart
ou urc
rate: 141.
2. Document the medication(s) that you administered.
o
Penicillin 5 million IU IVPB
aC s
vi y re
3. Document Ms. Patton’s pain during labor (severity during contractions, location, quality, interventions
taken, and response to interventions) and the measures that were taken to promote her desire for a
natural birth.
ed d
Uterus tone was soft between contractions. Regular contractions with moderate intensity had started.
ar stu
Contractions were approximately 4 minutes apart and lasting 50 seconds.
Pain: 2 between contractions., Location: everywhere
is
Th
4. Document your handoff report in the situation-background-assessment-recommendation (SBAR)
format to communicate what further care Ms. Patton needs.
sh
S: Brenda Patton is an 18-year-old Caucasian female, G1P0 at 38 2/7 weeks of gestation
admitted to the labor and birthing unit for labor assessment. The patient states that her
water may have broken earlier this morning and she thinks she is in labor. AmniSure
was positive. Vaginal exam reveals 50% effacement of cervix, cervical dilation 4 cm,
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
This study source was downloaded by 100000796901680 from CourseHero.com on 04-01-2021 15:55:30 GMT -05:00
https://www.coursehero.com/file/53301415/MaternityCase2-BPdocx/
