FutureRN2020
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.
Palpated the uterus for contractions. The uterus tone was soft between contractions. Regular
contractions with moderate intensity had started. Contractions were approximately 4 minutes
apart and lasting 50 seconds.
Fetal Heart rate: 140
Patient status - Heart rate: 89. Pulse: Present. Blood pressure: 119/71 mmHg. Respiration: 20.
Conscious state: Appropriate. SpO2: 97%. Temp: 37 C.
Occasional acceleration
2. Document the medication(s) that you administered.
Piggyback infusion of 5000000 IU of penicillin IV first dose then 2.5 million IU every 4 hour
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.
Location – abdomen pain due contractions
Level of pain 2 out 10 between contractions
No pain meds given, non-pharmacological interventions for pain and discomfort
Implemented comforting measures during painful contractions
Patient tolerated interventions and responded to assessment and medication given
4. Document your handoff report in the situation-background-assessment-recommendation (SBAR)
format to communicate what further care Ms. Patton needs.
SITUATION: Brenda Patton is an 18-year-old Caucasian female, G1P0 at 38 2/7 weeks of
gestation admitted to the L&D for labor assessment due to spontaneously ruptured
membrane. The patient wishes to have a natural birth without medications. She is currently
experiencing a pain level of 2/10 on the pain scale.
BACKGROUND: Patients AmniSure was positive; the lab report indicates that the patient's
group B strep vagino-rectal culture taken at 36 weeks was positive. The patient wishes to
have a natural birth without medication. Admission intrapartum orders have been initiated
and a saline lock has been placed in her forearm, piggyback infusion of 5 million IU of
penicillin IV was administered.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
This study source was downloaded by 100000809669238 from CourseHero.com on 02-18-2022 03:32:05 GMT -06:00
https://www.coursehero.com/file/64824811/Maternity-Case-2-Brenda-Pattondocx/
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.
Palpated the uterus for contractions. The uterus tone was soft between contractions. Regular
contractions with moderate intensity had started. Contractions were approximately 4 minutes
apart and lasting 50 seconds.
Fetal Heart rate: 140
Patient status - Heart rate: 89. Pulse: Present. Blood pressure: 119/71 mmHg. Respiration: 20.
Conscious state: Appropriate. SpO2: 97%. Temp: 37 C.
Occasional acceleration
2. Document the medication(s) that you administered.
Piggyback infusion of 5000000 IU of penicillin IV first dose then 2.5 million IU every 4 hour
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.
Location – abdomen pain due contractions
Level of pain 2 out 10 between contractions
No pain meds given, non-pharmacological interventions for pain and discomfort
Implemented comforting measures during painful contractions
Patient tolerated interventions and responded to assessment and medication given
4. Document your handoff report in the situation-background-assessment-recommendation (SBAR)
format to communicate what further care Ms. Patton needs.
SITUATION: Brenda Patton is an 18-year-old Caucasian female, G1P0 at 38 2/7 weeks of
gestation admitted to the L&D for labor assessment due to spontaneously ruptured
membrane. The patient wishes to have a natural birth without medications. She is currently
experiencing a pain level of 2/10 on the pain scale.
BACKGROUND: Patients AmniSure was positive; the lab report indicates that the patient's
group B strep vagino-rectal culture taken at 36 weeks was positive. The patient wishes to
have a natural birth without medication. Admission intrapartum orders have been initiated
and a saline lock has been placed in her forearm, piggyback infusion of 5 million IU of
penicillin IV was administered.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
This study source was downloaded by 100000809669238 from CourseHero.com on 02-18-2022 03:32:05 GMT -06:00
https://www.coursehero.com/file/64824811/Maternity-Case-2-Brenda-Pattondocx/
