Case Study for Care Map:
Scenario:
D.H. comes the labor and delivery unit having contractions and feeling somewhat uncomfortable. A nurse takes her to the intake room, provides privacy, has her change into a gown, and prepares for assessment.
1. What are the three initial questions a nurse should ask the client to determine whether to do a vaginal exam now or to continue asking more questions? Explain.
2. D.H. has contractions 2 to 3 minutes apart lasting 45 seconds. This is her third pregnancy (G3P2002) at 38 weeks gestation. The membranes are intact at this time. A nurse should most appropriately ask for what information before doing a vaginal exam?
3. What assessments should be done to gain further information from D.H?
4. The digital vaginal exam reveals 80% effacement, 4 cm dilated and -1 station. The fetal heart rate (FHR) is 150 beats/min and regular. The client is admitted to a labor and delivery room on the unit. What nursing measures should be done at this time?
5. Review the stages of labor. What stage is D.H. in at this time based on the above information?
6. D.H. is assessed with external electronic toco and fetus is assessed with an external electronic fetal monitor throughout labor. What abnormalities should a nurse assess for?
7. The nurse notes the following pattern on the external fetal monitoring strip. What are the most appropriate nursing interventions at this time?
8. The remainder of the labor is uneventful; D.H. has a 3rd degree episiotomy to allow more room for the infant to descend and delivers an 8 lb 8 oz male infant after 7 hours of labor and 20 minutes of pushing. What is involved in the immediate care of the newborn?
9. D.H. has her episiotomy repaired and the placenta delivered. Describe the signs that the placenta has released from the uterine wall?
10. Write the priority nursing diagnosis for D.H at this time in appropriate format with all data to support.
11. What is the goal for this diagnosis? Include three interventions that will resolve or relieve the problems with rationale.
12. What assessments are important for D.H. following delivery?
14. The infant at 30 hours of age has been breastfeeding since one hour after birth every 2-4 hours and a nurse observes the infant appropriately latching on the breast. The nurse notices 5 wet diapers and 2 meconium stools since birth on the intake and output sheet. Newborn assessement included a cephalohematoma. The infant has a yellow tinge to the sclera and skin. What is a nurse’s most appropriate next action?
15. What is the most likely cause(s) of the hyperbilirubinemia for this client?
16. The infant will be discharged home with the mother. Write one goal for the newborn based upon the information in questions 14 and 15.
17. Write appropriate discharge instructions that the nurse will teach the mother about the newborn’s prior to discharge. (These should relate directly to the stated goal in #16.)