Maternity Case: Brenda Patton
Documentation Assignments:
Problem 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.
Problem 2: Document the medication(s) that you administered.
Problem 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.
Problem 4: Document your handoff report in the situation-background-assessment-recommendation (SBAR) format to communicate what further care Ms. Patton needs.
Problem 5: Document the informal patient education that you provided to Ms. Patton during this scenario regarding group B streptococcus and the patient's response to this teaching session.