Problem
Ms. Claxmas has been able to come to all but one of her scheduled prenatal visits. She has been taking her blood pressure regularly at home and reports a range of 138-165/72-90. She has denied symptoms of headache (HA), epigastric pain, visual disturbances, shortness of breath, and dizziness. Urine dipstick at clinic visits has shown 0 to trace protein. Her asthma has been stable, with the occasional use of her inhaler. She denies the use of cocaine, other drugs, and alcohol. She states she is "trying to smoke only 2-3 cigarettes/day" but sometimes smokes up to ½ pack on stressful days. She is now 28 weeks pregnant.
Assessment Data is as follows
Assessment data:
Maternal VS: BP 154/82, HR 98, RR 20, T 98.80 F
FHR baseline: 150 with moderate variability; + accelerations noted; occasional variable decelerations noted
Occasional contractions: ~ 3-4/hour
+ fetal movement
No vaginal bleeding or loss of fluid
No abdominal pain or tenderness
Pt denies HA, visual disturbances, right upper quadrant pain; urine dipstick trace protein
Ms. Claxmas is stable at home until 30 weeks gestation. At that time she returns to the hospital complaining of vague lower abdominal pain with a gush of vaginal bleeding ~1 ½ hours ago, soaking 2 pads within 2 hours. The bleeding has tapered off to spotting. She reports + nausea and abdominal cramping; pain 3/10.
External fetal monitor (EFM) & Tocodynamometer (TOCO) are applied and show a FHR baseline of 150, moderate variability, occasional accelerations, no decelerations noted; + uterine irritability noted with mild contractions ~ 3-4 minutes apart VS: BP 168/82; HR 102; RR 20; T 98.10 F
¢External fetal monitor (EFM) & Tocodynamometer (TOCO) are applied and show a FHR baseline of 150, moderate variability, occasional accelerations, no decelerations noted; + uterine irritability noted with mild contractions ~ 3-4 minutes apart
VS: BP 168/82; HR 102; RR 20;
T 98.10 F
Placenta previa ruled out per ultrasound (us). No clots noted on u/s. Speculum exam confirms ~10 mL blood in vault, no clots; 1 cm dilated visually. Vaginal bleeding continues: small amounts of occasional bright red spotting on pads. FHTs remain reassuring.+ UDS Patient admitted for high risk antepartum surveillance
At 2330, the nurse notes that FHR baseline has increased to 170 with no accelerations, and repetitive late decelerations. Vaginal bleeding has increased, and patient reports sharp abdominal pain (8/10) with uterine tenderness on palpation. Contractions have increased in frequency, ~ 2-3 min apart and uterus remains firm between contractions.
VS: BP 150/72 ; HR 110; RR 22; Temp 97.90F; Pulse oximeter (pox) on room air 96%
I. Based on the initial assessment, what are the priority nursing interventions for Ms. Johnson?
II. After 2 hours of observation with no change in pt status, the physician ordered the administration of RhoGAM. Why? and what is the purpose of Rhogam? What procedures would be in place to give rhogam?
III. What do you suspect may be occurring? Based on the initial assessment, what are the priority nursing interventions for Ms. Johnson? WHat Labs would you want to get? What things would you discuss with the patient? WHat would you teach the patient?
IV. What is your suspected problem now?
V. What are your priority interventions?