Maternity Case 1: Olivia Jones
Documentation Assignments
1. Document the data from your focused antepartum assessment of both Ms. Jones and the fetus.
Patient status - Heart rate: 112. Pulse: Present. Blood pressure: 174/104 mmHg. Respiration: 22.
Conscious state: Appropriate. SpO2: 92%. Temp: 37 C. EFM: Occasional acceleration. Fetal heart rate:
154. Pt c/o of pain, rated 5. Pain is across forehead and c/o of epigastric pain. Pt. is experiencing visual
disturbances, blurred vision and she sees, “some spots.” Pt. has normal elasticity of the skin and she is
cool and very sweaty. She is breathing at 22 breaths per minute. The chest is moving equally. Leopold
maneuvers were performed. The fetus is in longitudinal lie, in vertex presentation. Pt has moderate to
m
severe pitting edema, graded to +3. Crackles at both lung bases upon auscultation. FHR is 165 bpm, fetus
er as
is tachycardic. Deep tendon reflexes were very brisk, hyperflexive, and with clonus, graded to +4. Bladder
co
status: bladder contained 81 mL of urine. Palpation of uterus: uterus tone is moderate between
eH w
contractions. No contractions were noted. Fetal movement was felt. IV site has no redness, swelling,
o.
infiltration, bleeding, or drainage. The dressing is dry and intact.
rs e
ou urc
2. Write the situation-background-assessment-recommendation (SBAR) communications you
would use to update the provider on Ms. Jones’s status at the time of her admission.
o
This is nurse Derek from L&D calling about your patient Ms. Jones. She is a 26 year old female, 36 of
aC s
gestation who has been admitted for severe eclampsia. Her BP is currently 174/104 and heart rate is
vi y re
112. She is complaining of a severe headache and epigastric pain. She has had a normal pregnancy until
she was diagnosed with preeclampsia at 30 weeks’ gestation. Her symptoms have worsened. FHR is 162
and fetal movement was felt upon palpation of the uterus. An ultrasound was performed. Her bladder
ed d
scan showed retained urine, so the Foley catheter has been placed. She feels nauseated. She also
ar stu
expresses visual changes and reports her vision is blurred and is seeing spots. I recommend you come
see the patient because I think she might need to deliver the baby in order to prevent any further
negative affect on the maternal health status. In the meantime would you like to put in an order of
is
Magnesium sulfate for me to begin infusing?
Th
3. Document the teaching you would provide to the patient and her support person prior to
administering magnesium sulfate.
I would teach the patient about her condition and how the medication will help. I would also provide
sh
information about the side effects that can be experienced when being given magnesium sulfate.
4. Document the administration of the magnesium sulfate bolus and the initiation of the
magnesium sulfate infusion.
Magnesium sulfate in sterile water (6g in 100 mL) at 200 mL/hr via IV of the L antecubital region at 1620.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
This study source was downloaded by 100000796901680 from CourseHero.com on 04-01-2021 16:54:14 GMT -05:00
https://www.coursehero.com/file/50561629/Olivia-Jones-Documentation-docx/
Documentation Assignments
1. Document the data from your focused antepartum assessment of both Ms. Jones and the fetus.
Patient status - Heart rate: 112. Pulse: Present. Blood pressure: 174/104 mmHg. Respiration: 22.
Conscious state: Appropriate. SpO2: 92%. Temp: 37 C. EFM: Occasional acceleration. Fetal heart rate:
154. Pt c/o of pain, rated 5. Pain is across forehead and c/o of epigastric pain. Pt. is experiencing visual
disturbances, blurred vision and she sees, “some spots.” Pt. has normal elasticity of the skin and she is
cool and very sweaty. She is breathing at 22 breaths per minute. The chest is moving equally. Leopold
maneuvers were performed. The fetus is in longitudinal lie, in vertex presentation. Pt has moderate to
m
severe pitting edema, graded to +3. Crackles at both lung bases upon auscultation. FHR is 165 bpm, fetus
er as
is tachycardic. Deep tendon reflexes were very brisk, hyperflexive, and with clonus, graded to +4. Bladder
co
status: bladder contained 81 mL of urine. Palpation of uterus: uterus tone is moderate between
eH w
contractions. No contractions were noted. Fetal movement was felt. IV site has no redness, swelling,
o.
infiltration, bleeding, or drainage. The dressing is dry and intact.
rs e
ou urc
2. Write the situation-background-assessment-recommendation (SBAR) communications you
would use to update the provider on Ms. Jones’s status at the time of her admission.
o
This is nurse Derek from L&D calling about your patient Ms. Jones. She is a 26 year old female, 36 of
aC s
gestation who has been admitted for severe eclampsia. Her BP is currently 174/104 and heart rate is
vi y re
112. She is complaining of a severe headache and epigastric pain. She has had a normal pregnancy until
she was diagnosed with preeclampsia at 30 weeks’ gestation. Her symptoms have worsened. FHR is 162
and fetal movement was felt upon palpation of the uterus. An ultrasound was performed. Her bladder
ed d
scan showed retained urine, so the Foley catheter has been placed. She feels nauseated. She also
ar stu
expresses visual changes and reports her vision is blurred and is seeing spots. I recommend you come
see the patient because I think she might need to deliver the baby in order to prevent any further
negative affect on the maternal health status. In the meantime would you like to put in an order of
is
Magnesium sulfate for me to begin infusing?
Th
3. Document the teaching you would provide to the patient and her support person prior to
administering magnesium sulfate.
I would teach the patient about her condition and how the medication will help. I would also provide
sh
information about the side effects that can be experienced when being given magnesium sulfate.
4. Document the administration of the magnesium sulfate bolus and the initiation of the
magnesium sulfate infusion.
Magnesium sulfate in sterile water (6g in 100 mL) at 200 mL/hr via IV of the L antecubital region at 1620.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
This study source was downloaded by 100000796901680 from CourseHero.com on 04-01-2021 16:54:14 GMT -05:00
https://www.coursehero.com/file/50561629/Olivia-Jones-Documentation-docx/
