Maternal-Newborn SR (83 expert
questions and answers)
Carly Madison
30 y/o G1P0 who was admitted 4 hours ago in labor. Her cervical
exam on admit revealed: 4 cm, 70%, fetal vertex at -1, slight
bloody show, leaking membranes. She doesn’t remember when
the leaking began. Contractions on admit were q 5 minutes x 45
seconds. Mrs. Madison reported a pain level at 4/10. She and her
husband have been to a Lamaze Prepared Childbirth series and
their Birth Plan includes the desire for a non-medicated labor and
birth. She and her husband have been doing Slow-Chest breathing
and conscious relaxation techniques since admission. She is NPO
other than ice chips; she has no IV at this point. Vital signs – BP
124/70, P 80, R 20, FHR is reassuring with a 136 BPM baseline
with moderate variability no decelerations and +accelerations
(Category 1). She is ambulating in her room with a portable
maternal-fetal monitor applied. She puts her call light on and ask
to see a nurse stating, “how much longer is this going to be? I am
getting really tired.”
Physiological
Acute Pain
Anxiety Related to Labor and Birthing Process
Fatigue Related to Energy Expenditure Required for Labor and
Coping Skills
Impaired Comfort
Risk for Fluid Volume Deficit
Safety
,Deficient Knowledge
Risk for Maternal Infection
Maria Sanchez
20-year-old female, G1 P1 L1, 39 weeks gestation. Pregnancy
uncomplicated. O+, Rubella immune, Group B Strep negative.
NKDA. 12-hour 1st stage, 1 hour 2nd stage, 10 minute 3rd stage.
Spontaneous vaginal delivery with 1st degree perineal laceration
one hour ago. Vital signs stable; fundus firm, midline, at
umbilicus; Lochia rubra moderate, no clots; Up to bathroom x1-
500 mL, no dysuria, instructed on peri-care; Legs still a little
“tingly” but able to bear weight with assist X2. Pain level 3/10- ice
to perineum with relief. Neonate male- Juan- 3500 g; Apgar 8 & 9;
T 36.8 C, 98.2 F; AP 156 beats/minute, regular; R 52
breaths/minute, irregular. Skin-to-skin with mother for first hour.
Beginning to show hunger cues. Their plan is do both breast and
bottle feeding; “las dos cosas.” Maria’s husband Raul is a quiet
presence. Her mother, grandmother, and older sister were Maria’s
support persons in labor. Maria and Raul are bilingual in English
and Spanish. They were both born in the US- are Mexican
Americans. Her mother speaks and understands more English
than her grandmother does.
Saftey
Fall Risk
Injury, risk for maternal
Physiological
Acute Pain
Ineffective breastfeeding, risk for
Infection, risk for
Love and Belonging
,Deficient Knowledge
Readiness for Enhanced Parenting
Ms. Susie Smith
33 y/o G2P0 at 42 weeks’ gestation. She is single with a limited
support system. She has just completed a Non-Stress Test (NST)
which was interpreted as being Non-Reactive. Her obstetrician has
now ordered an Oxytocin-Stimulated Contraction Stress Test
(CST). Fetal membranes are intact. Ms. Smith also has a history of
hypertension and a previous pregnancy loss at 18 weeks’
gestation. She is crying and states “I can’t lose another baby”.
External tocodynamometer and fetal ultrasound transducer
remain in place from the NST.
Physiological
Anxiety
Risk for Impaired Fetal Gas Exchange
Safety
Deficient Knowledge
Fall, Risk for
Maternal Injury, Risk for
Risk for Ineffective Coping
Sarah Lane
Mrs. Sarah Lane is a 25 y/o G2P0 who is at 42 weeks gestation.
Estimated fetal weight is 4000 Gm. She presents to the Maternal-
Fetal Medicine Clinic today for a Non-Stress Test (NST). Her first
pregnancy ended in a miscarriage at 10 weeks gestation. Her
husband has accompanied her to every prenatal visit; they both
appear anxious regarding the test and the health of their baby.
Physiological
, Anxiety
Risk for Fetal Injury
Risk for Impaired Fetal Gas Exchange
Safety
Deficient knowledge
Fall, Risk for
Risk for Ineffective Individual Coping
Risk for Maternal Injury
Carly Madison Scenario 1
You enter the patient’s room. After washing and gloving hands,
you identify yourself and the patient, Mrs. Carly Madison. She
appears anxious, has switched to shallow-chest breathing and is
now sitting in the rocking chair. She says she hasn’t had a cervical
exam since she was admitted and is anxious to see if she has
progressed any. Her Healthcare Provider arrives to examine her
and states he may perform an amniotomy (AROM). SELECT THE
FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD
BE IMPLEMENTED:
Offer support and explain to the woman what will be done,
assisting her to a lithotomy position with slight lateral tilt.
Assess the FHR before procedure to obtain a baseline reading.
Place a clean, dry pad under the woman's buttocks to absorb
fluid.
Assist the healthcare provider who is performing exam by opening
sterile gloves, lubricant and sterile amniotomy hook.
questions and answers)
Carly Madison
30 y/o G1P0 who was admitted 4 hours ago in labor. Her cervical
exam on admit revealed: 4 cm, 70%, fetal vertex at -1, slight
bloody show, leaking membranes. She doesn’t remember when
the leaking began. Contractions on admit were q 5 minutes x 45
seconds. Mrs. Madison reported a pain level at 4/10. She and her
husband have been to a Lamaze Prepared Childbirth series and
their Birth Plan includes the desire for a non-medicated labor and
birth. She and her husband have been doing Slow-Chest breathing
and conscious relaxation techniques since admission. She is NPO
other than ice chips; she has no IV at this point. Vital signs – BP
124/70, P 80, R 20, FHR is reassuring with a 136 BPM baseline
with moderate variability no decelerations and +accelerations
(Category 1). She is ambulating in her room with a portable
maternal-fetal monitor applied. She puts her call light on and ask
to see a nurse stating, “how much longer is this going to be? I am
getting really tired.”
Physiological
Acute Pain
Anxiety Related to Labor and Birthing Process
Fatigue Related to Energy Expenditure Required for Labor and
Coping Skills
Impaired Comfort
Risk for Fluid Volume Deficit
Safety
,Deficient Knowledge
Risk for Maternal Infection
Maria Sanchez
20-year-old female, G1 P1 L1, 39 weeks gestation. Pregnancy
uncomplicated. O+, Rubella immune, Group B Strep negative.
NKDA. 12-hour 1st stage, 1 hour 2nd stage, 10 minute 3rd stage.
Spontaneous vaginal delivery with 1st degree perineal laceration
one hour ago. Vital signs stable; fundus firm, midline, at
umbilicus; Lochia rubra moderate, no clots; Up to bathroom x1-
500 mL, no dysuria, instructed on peri-care; Legs still a little
“tingly” but able to bear weight with assist X2. Pain level 3/10- ice
to perineum with relief. Neonate male- Juan- 3500 g; Apgar 8 & 9;
T 36.8 C, 98.2 F; AP 156 beats/minute, regular; R 52
breaths/minute, irregular. Skin-to-skin with mother for first hour.
Beginning to show hunger cues. Their plan is do both breast and
bottle feeding; “las dos cosas.” Maria’s husband Raul is a quiet
presence. Her mother, grandmother, and older sister were Maria’s
support persons in labor. Maria and Raul are bilingual in English
and Spanish. They were both born in the US- are Mexican
Americans. Her mother speaks and understands more English
than her grandmother does.
Saftey
Fall Risk
Injury, risk for maternal
Physiological
Acute Pain
Ineffective breastfeeding, risk for
Infection, risk for
Love and Belonging
,Deficient Knowledge
Readiness for Enhanced Parenting
Ms. Susie Smith
33 y/o G2P0 at 42 weeks’ gestation. She is single with a limited
support system. She has just completed a Non-Stress Test (NST)
which was interpreted as being Non-Reactive. Her obstetrician has
now ordered an Oxytocin-Stimulated Contraction Stress Test
(CST). Fetal membranes are intact. Ms. Smith also has a history of
hypertension and a previous pregnancy loss at 18 weeks’
gestation. She is crying and states “I can’t lose another baby”.
External tocodynamometer and fetal ultrasound transducer
remain in place from the NST.
Physiological
Anxiety
Risk for Impaired Fetal Gas Exchange
Safety
Deficient Knowledge
Fall, Risk for
Maternal Injury, Risk for
Risk for Ineffective Coping
Sarah Lane
Mrs. Sarah Lane is a 25 y/o G2P0 who is at 42 weeks gestation.
Estimated fetal weight is 4000 Gm. She presents to the Maternal-
Fetal Medicine Clinic today for a Non-Stress Test (NST). Her first
pregnancy ended in a miscarriage at 10 weeks gestation. Her
husband has accompanied her to every prenatal visit; they both
appear anxious regarding the test and the health of their baby.
Physiological
, Anxiety
Risk for Fetal Injury
Risk for Impaired Fetal Gas Exchange
Safety
Deficient knowledge
Fall, Risk for
Risk for Ineffective Individual Coping
Risk for Maternal Injury
Carly Madison Scenario 1
You enter the patient’s room. After washing and gloving hands,
you identify yourself and the patient, Mrs. Carly Madison. She
appears anxious, has switched to shallow-chest breathing and is
now sitting in the rocking chair. She says she hasn’t had a cervical
exam since she was admitted and is anxious to see if she has
progressed any. Her Healthcare Provider arrives to examine her
and states he may perform an amniotomy (AROM). SELECT THE
FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD
BE IMPLEMENTED:
Offer support and explain to the woman what will be done,
assisting her to a lithotomy position with slight lateral tilt.
Assess the FHR before procedure to obtain a baseline reading.
Place a clean, dry pad under the woman's buttocks to absorb
fluid.
Assist the healthcare provider who is performing exam by opening
sterile gloves, lubricant and sterile amniotomy hook.
