Maternal-Newborn Nursing Clinical Case
Studies with Answers & Rationales | High-
Scoring A+ Simulation Pack
Jennifer Humes Room 301
Jennifer Humes, 30-year-old Caucasian female, G4 T2 P0 A1 L2, 33 5/7 weeks gestation. History of chronic hypertension
and gestational hypertension with this pregnancy. Nifedipine XL 30 mg daily. NKDA. Previous pregnancies uncomplicated
with NSVDs. One spontaneous abortion at 10 weeks gestation. Woke up early morning feeling wet; wasn’t sure if leaking
urine or membranes ruptured. Turned on light and it was blood. Asked a neighbor to come over to watch other children
and husband brought her to hospital. They are making phone calls to get family member to come and take care of 5 and
2-year old children. Anxious about this pregnancy and bleeding too. Has mild abdominal pain and contractions.
,You responded correctly to 5 out of 6 evaluations:
Category Your response Explanation
Educational Needs Increased acuity Status assessment reports r/t change in condition.
Fall Risk Increased acuity Status assessment reports r/t 34 weeks gestation and pain, change in center of gravity.
Health change Increased acuity Status assessment reports r/t complication of pregnancy and bleeding.
Pain level Increased acuity Status assessment reports r/t abdominal pain and mild contractions.
Physiological Needs Increased acuity Status assessment reports r/t concern about condition and care of other children.
Sensorium Needs Normal acuity Status assessment reports no problems related to sensorium indicated in the report.
,Jenny Theriot Room 302
Jenny Theriot, 30 y/o G1P0 at 31 weeks’ gestation. She has had an uncomplicated pregnancy until this morning when she
woke up with clear fluid leaking from her vagina. She denies having contractions but says she isn’t really sure what she is
feeling. She presents to the Obstetrics Triage Unit, looking distraught and crying, and says she doesn’t understand what is
going on.
Category Your response Explanation
Educational Increased Status assessment reports leaking of fluid from vagina, possible contractions and preterm delivery. These should be the subject of
Needs acuity teaching and support for the client.
Fall Risk Increased Status assessment reports the client is pregnant; this changed her center of gravity and balance.
acuity
Health change Increased Status assessment reports leaking of fluid from vagina and possible contractions.
acuity
Pain level Decrease Status assessment does not indicate report of pain.
acuity
Physiological Increased Status assessment reports leaking of fluid from vagina, possible contractions.
Needs acuity
Sensorium Needs Normal acuity Status assessment
, Kesha Jackson Room 303
Kesha Jackson, Kesha Jackson is a G1P0, gestational age of 33.1. She came in complaining of contractions for 2 hours that
are now every 5 mins. She is unsure about rupture of membranes, denying vaginal bleeding and recent intercourse. She
states the baby is active. She rates her pain an 8/10. Her current vital signs are 98.1o F., 92 BPM, 16 breaths/min, 122/64
mmHg, 99% on room air. The fetal heart rate is 135 baseline but is not yet reactive. Cervical exam reveals that she is not
dilated or effaced, and the baby’s head is not engaged in the pelvis. She has no medical history and NKA. In obtaining her
history, it was learned that she is 15 years old, currently homeless, and has been staying with various friends. She does
have some supplies including diapers, wipes, and some clothing that she received from a friend. She expresses the desire
to take her baby home with her. She is receptive to teaching and assistance she just has been unsure of how to obtain it.
She came to the OB triage via a bus.
Category Your response Explanation
Educational Needs Increased Status Assessment reports Kesha will need a lot of education regarding preterm labor precautions, resources for assistance, and
acuity caring for her baby once it arrives
Fall Risk Increased Status Assessment reports Client is at increased of fall due to changing center of gravity and balance.
acuity
Health Change Increased Status Assessment reports in addition to the pregnancy, there are now additional health issues due to the preterm labor.
acuity
Studies with Answers & Rationales | High-
Scoring A+ Simulation Pack
Jennifer Humes Room 301
Jennifer Humes, 30-year-old Caucasian female, G4 T2 P0 A1 L2, 33 5/7 weeks gestation. History of chronic hypertension
and gestational hypertension with this pregnancy. Nifedipine XL 30 mg daily. NKDA. Previous pregnancies uncomplicated
with NSVDs. One spontaneous abortion at 10 weeks gestation. Woke up early morning feeling wet; wasn’t sure if leaking
urine or membranes ruptured. Turned on light and it was blood. Asked a neighbor to come over to watch other children
and husband brought her to hospital. They are making phone calls to get family member to come and take care of 5 and
2-year old children. Anxious about this pregnancy and bleeding too. Has mild abdominal pain and contractions.
,You responded correctly to 5 out of 6 evaluations:
Category Your response Explanation
Educational Needs Increased acuity Status assessment reports r/t change in condition.
Fall Risk Increased acuity Status assessment reports r/t 34 weeks gestation and pain, change in center of gravity.
Health change Increased acuity Status assessment reports r/t complication of pregnancy and bleeding.
Pain level Increased acuity Status assessment reports r/t abdominal pain and mild contractions.
Physiological Needs Increased acuity Status assessment reports r/t concern about condition and care of other children.
Sensorium Needs Normal acuity Status assessment reports no problems related to sensorium indicated in the report.
,Jenny Theriot Room 302
Jenny Theriot, 30 y/o G1P0 at 31 weeks’ gestation. She has had an uncomplicated pregnancy until this morning when she
woke up with clear fluid leaking from her vagina. She denies having contractions but says she isn’t really sure what she is
feeling. She presents to the Obstetrics Triage Unit, looking distraught and crying, and says she doesn’t understand what is
going on.
Category Your response Explanation
Educational Increased Status assessment reports leaking of fluid from vagina, possible contractions and preterm delivery. These should be the subject of
Needs acuity teaching and support for the client.
Fall Risk Increased Status assessment reports the client is pregnant; this changed her center of gravity and balance.
acuity
Health change Increased Status assessment reports leaking of fluid from vagina and possible contractions.
acuity
Pain level Decrease Status assessment does not indicate report of pain.
acuity
Physiological Increased Status assessment reports leaking of fluid from vagina, possible contractions.
Needs acuity
Sensorium Needs Normal acuity Status assessment
, Kesha Jackson Room 303
Kesha Jackson, Kesha Jackson is a G1P0, gestational age of 33.1. She came in complaining of contractions for 2 hours that
are now every 5 mins. She is unsure about rupture of membranes, denying vaginal bleeding and recent intercourse. She
states the baby is active. She rates her pain an 8/10. Her current vital signs are 98.1o F., 92 BPM, 16 breaths/min, 122/64
mmHg, 99% on room air. The fetal heart rate is 135 baseline but is not yet reactive. Cervical exam reveals that she is not
dilated or effaced, and the baby’s head is not engaged in the pelvis. She has no medical history and NKA. In obtaining her
history, it was learned that she is 15 years old, currently homeless, and has been staying with various friends. She does
have some supplies including diapers, wipes, and some clothing that she received from a friend. She expresses the desire
to take her baby home with her. She is receptive to teaching and assistance she just has been unsure of how to obtain it.
She came to the OB triage via a bus.
Category Your response Explanation
Educational Needs Increased Status Assessment reports Kesha will need a lot of education regarding preterm labor precautions, resources for assistance, and
acuity caring for her baby once it arrives
Fall Risk Increased Status Assessment reports Client is at increased of fall due to changing center of gravity and balance.
acuity
Health Change Increased Status Assessment reports in addition to the pregnancy, there are now additional health issues due to the preterm labor.
acuity
