Time: 1!" Heather Morris, RN, has just arrived to work her evening shift in Labor & Delivery. This is her th year as an RN in the unit. !hile waiting for re"ort on her "atient she reviews the #hart, revealing the following$
Melanie %auer, ad&itted ' hours ago, is a '()year)old gravida ' "ara *)()*)* &arried wo&an whose e+"e#ted date of delivery is today. Her ,rst "renatal visit was at *- weeks and she had *( visits total. Melanie.s lab work in#ludes$ He&oglobin$ *-g/dL %lood ty"e$ 0 negative 1DRL$ non)rea#tive 2rinalysis$ nor&al Rubella titer$ *$*( He"atitis % s#reen 3Hbs0g4$ negative H51 s#reen$ negative 6a" s&ear$ Negative 7igni,#ant infor&ation$ Melanie.s "re)"regnan#y weight was *8( "ounds, weight gain was 8(9. Her baseline blood "ressure was **(/:8, %6.s re&ained **()*-(/:8);( throughout her "regnan#y. Her routine urine sa&"les were nor&al and her #hart reveals nor&al fetal growth throughout her "regnan#y. 7he had - ultrasounds and did not want to know the se+ of her baby. 0 <uad &arker s#reen at *: weeks was within nor&al li&its. Melanie had a glu#ose s#reen at -8 weeks with a "las&a glu#ose level of **( &g/dL. Her =rou" % stre" s#reen at ': weeks was "ositive. 7he re&ained healthy and a#tive and &edi#ations in#luded only "renatal vita&ins daily. 7he did re"ort "roble&s with #onsti"ation and he&orrhoids during her "regnan#y. 5n re"ort, Heather learns that at her last e+a& * hour ago$ Melanie.s #ervi+ was dilated to : #& and >(? e@a#ed, at a Aero station. The baby.s "osition is RB0. 7"ontaneous ru"ture of &e&branes o##urred at ho&e : hours ago, Cuid was #lear. Melanie is having strong #ontra#tions every - &inutes, lasting :( se#onds. Detal heart tones are *8()*( with good variability. 1ital signs$ HR E F(, RR E -(, Te&" E FF.>, %6 E *--/;-. 7he has an 51 of LR in her right ar& that is saline lo#ked. 7he and her husband are using their breathing te#hni<ues and &anaging the #ontra#tions well. They are really "leased that they did not have to be indu#ed again like last ti&e. Melanie ho"es to have a natural #hildbirth without the use of drugs, whi#h she also a##o&"lished with her ,rst delivery. 7he did relate that her #ontra#tions see& stronger this ti&e and she &ay be rethinking that de#ision. Melanie.s husband Mark is with her in labor, they have taken #hildbirth "re"aration #lasses. Mark was also "resent for the vaginal delivery of their son 7i&on who was born - years ago. The Gerti,ed Nurse Midwife will be attending the delivery though she is not #urrently on the unit. 0s the day shift RN leaves for ho&e, Heather "lans her evening and thinks$ H5 anti#i"ate a routine delivery within the ne+t few hours.I I# you $ere caring #or Melanie% &ere are some 'uestions to (onder !hat s#reenings were done antenatally and whyJwhat other s#reenings &ight have been doneK 0re #onsti"ation and he&orrhoids in "regnan#y nor&alK !hyK !hat are other dis#o&forts of "regnan#yK !hat is the signi,#an#e of the #lient.s Rh negative statusK 5s her weight gain a""ro"riate for her "regnan#yK !hat are the i&"li#ations of &edi#ations/drug use/ s&oking use in "regnan#y 3in#luding "renatal vita&ins and foli# a#id4K !hat the &eaning of ='6*(**K !hat is the signi,#an#e and e+"e#ted &anage&ent of her grou" % stre" "ositive statusK !hat stage of labor is she in and how does the baby.s "osition a@e#t the "rogression of laborK How does a "atient stay hydrated in laborK !hat are the i&"li#ations of a full bowel or bladder in laborK !hat breathing te#hni<ues would be &ost advantageous for the "atient to use in labor in ea#h stageK How #an the nurse su""ort the fa&ily unitK !hat non)"har&a#ologi#al #o&fort &easures #an the nurse "rovideK How does the nurse "re"are for a routine deliveryK How is the laboring "rogress des#ribed and what is is the e+"e#ted #ourse of laborK 5f Melanie does #hange her &ind regarding &edi#ation in labor, what &ight you suggest and what are the i&"li#ations for the fetusK !hat are standards of #are related to fetal &onitoring and do#u&entationK How would you do#u&ent her labor "rogressK !hat would #on#ern you on the fetal &onitor tra#ingK Time: 1)3* 0s Heather "re"ares to &eet her "atient and do an assess&ent, Mark runs out of the labor roo& and is #learly u"set and an+ious. He yells$ HLou need to hurry, she wants soðing for "ain and she says she feels like "ushing. The baby.s heart rate is slowing down and 5 #an hear itMI Heather knows that the nurse &idwife is at ho&e at least -( &inutes fro& the hos"ital. Heather re#alls that at the last e+a& one hour ago, Melanie was only : #enti&eters dilated and only >(? e@a#ed. 7he had "lanned to ask Melanie how long her labor was with her son, but is now #on#erned that this labor &ay be "rogressing &ore <ui#kly. 7he is #on#erned that Mark is an+ious and worried and #learly wants her attention. !hat should the nurse do ,rstK !hat would you in#lude in your 7%0R #o&&uni#ation with the "roviderK !hat is the infor&ation a#<uired during a vaginal e+a&K How do you assess fetal status and what would you e+"e#t as nor&alK !hat is the signi,#an#e of feeling "ushyK !hat does Heather need to know about "ain &anage&ent at this "oint in laborK !hat is the best res"onse to Mark to hel" hi& &anage his an+ieties about the babyK Time: +1** The &idwife, Gara, has been on the unit for one hour. 7he ordered Nubain *( &g 51 whi#h was given when she arrived. Melanie is now #o&"letely dilated and she has been "ushing for ten &inutes. The baby is #rowning. The DHT.s are dro""ing down to F( b"& fro& a *8(b"& baseline with ea#h #ontra#tion. Mark #ontinues to su""ort her and see&s to be less an+ious now that Gara is here. He has <uestions regarding whether an e"isioto&y #ould hel" labor "rogress faster, and is this a&ount of bleeding nor&alK He #ontinues to e+"ress #on#ern about the fetal heart rate dro""ing. !hat e@e#t is Nubain going to have on the fetus and how will this a@e#t nursing #are of the infantK !hat are indi#ations for an e"isioto&y and nursing i&"li#ations for "atient tea#hingK !hat is the esti&ated blood loss for a nor&al vaginal deliveryK How will blood loss i&"a#t he&oglobin, he&ato#rit and vital signsK How and why do DHT.s #hange during a nor&al deliveryK
Time: +11* Melanie delivers a baby boy who is i&&ediately "la#ed on her abdo&en. His 0"gars are > at one &inute and F at ,ve &inutes. Gara waits *( &inutes for the "la#enta to be delivered inta#t. 7haron "ersuades Mark to #ut the #ord and he has tears in his eyes as he and Melanie &arvel over their new son. The baby is awake and Melanie wants to know if it is too soon to breastfeed. They begin dis#ussing the need to have their baby #ir#u&#ised and ask you for your thoughts on the &atter. !hat is involved in the i&&ediate #are of the newbornK How should the nurse res"ond to Melanie.s <uestion about breastfeedingK !hat #an be e+"e#ted of the infant.s behavior over the ne+t few hoursK !hat assess&ents should the nurse do for a newborn and what tea#hing is #riti#alK !hat is involved in Melanie.s "ost)"artu& #he#ks and what are nor&al ,ndingsK !hat tea#hing will Melanie need before she is dis#hargedK How should the nurse res"ond to Melanie and Mark.s <uestions about the ne#essity for #ir#u&#isionK !hat infor&ation should the nurse give Melanie regarding follow)u" #are for herself and the babyK