Renee_Wilson_maternal
Renee Wilson Room 302
Renee Wilson, 26 y/o G1P0 admitted four hours ago to the Birthing Center.
She has had an uncomplicated pregnancy, but her obstetrician has
expressed the concern about needing a c-section because of the anticipation
of a large baby. Her last ultrasound estimated fetal weight at 9 lbs. 6 oz. She
and her husband have attended Lamaze Prepared Childbirth Classes and
their Birth Plan includes the desire to have an unmedicated labor and vaginal
birth. She also desires skin to skin contact with her baby at birth and
breastfeeding. Admit assessment findings: Sterile vaginal exam (SVE) - 4 cm,
80% effaced, and fetal vertex at a -2 station with intact membranes, slight
bloody show. BP 110/70 mmHg, P. 88 beats/minute, R 24 breaths/minute; T
98.8 F. 37.1 C. FHR 150 baseline with moderate variability + accelerations,
absent decelerations (Category 1). Contractions are occurring every 2
minutes, lasting 60 seconds with moderate intensity per palpation. Portable
tocodynamometer and fetal ultrasound transducer are in place. She is using
shallow-chest breathing and conscious relaxation techniques and is
ambulating in her room. She rates her pain at 5/10. She tells you that she
will feel like a failure if she can’t deliver vaginally.
You responded correctly to 5 out of 6 evaluations:
Your
Category response Explanation
Educational Increased Status assessment reports she is a G1 having attended childbirth classes, but
Needs acuity first-time mothers require focused education and reinforcement of concepts
learned.
Fall Risk Increased Health change Increased
acuity acuity
1
, Renee_Wilson_maternal
Status assessment
reports she is
pregnant and is
experiencing changes
inbalance and center
of gravity.
Patient is in labor and is
experiencing a change in
health status.
2
Renee Wilson Room 302
Renee Wilson, 26 y/o G1P0 admitted four hours ago to the Birthing Center.
She has had an uncomplicated pregnancy, but her obstetrician has
expressed the concern about needing a c-section because of the anticipation
of a large baby. Her last ultrasound estimated fetal weight at 9 lbs. 6 oz. She
and her husband have attended Lamaze Prepared Childbirth Classes and
their Birth Plan includes the desire to have an unmedicated labor and vaginal
birth. She also desires skin to skin contact with her baby at birth and
breastfeeding. Admit assessment findings: Sterile vaginal exam (SVE) - 4 cm,
80% effaced, and fetal vertex at a -2 station with intact membranes, slight
bloody show. BP 110/70 mmHg, P. 88 beats/minute, R 24 breaths/minute; T
98.8 F. 37.1 C. FHR 150 baseline with moderate variability + accelerations,
absent decelerations (Category 1). Contractions are occurring every 2
minutes, lasting 60 seconds with moderate intensity per palpation. Portable
tocodynamometer and fetal ultrasound transducer are in place. She is using
shallow-chest breathing and conscious relaxation techniques and is
ambulating in her room. She rates her pain at 5/10. She tells you that she
will feel like a failure if she can’t deliver vaginally.
You responded correctly to 5 out of 6 evaluations:
Your
Category response Explanation
Educational Increased Status assessment reports she is a G1 having attended childbirth classes, but
Needs acuity first-time mothers require focused education and reinforcement of concepts
learned.
Fall Risk Increased Health change Increased
acuity acuity
1
, Renee_Wilson_maternal
Status assessment
reports she is
pregnant and is
experiencing changes
inbalance and center
of gravity.
Patient is in labor and is
experiencing a change in
health status.
2
