You are the charge nurse working in labor and delivery at a local hospital. D.H. comes to the unit having contractions and feeling somewhat uncomfortable. You take her to the intake room to provide privacy, have her change into a gown, and ask her three initial questions to determine your next course of action, that is, whether to do a vaginal exam or to continue asking her more questions.
1. What three initial questions will you ask, and why?
What brings you to the hospital today? The nurse should ask open-ended questions to allow the patient to
Articulate her concerns. The priority is to establish a therapeutic relationship with the patient. (Durham & Chapman, 2014, p. 206)
How many weeks pregnant? The nurse should determine the gestational
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age of the patient. The nurse’s intervention is established based on whether or not the fetus is term or preterm. If the patient present with a gestational age earlier than 36 weeks, the fetus could be at risk for neonatal complications. (Durham & Chapman, 2014, p. 195-107) What time did your contractions begin and about how far apart are they? This will assist the nurse in determining whether or not the patient is in true labor. According to Durham & Chapman (2014), True labor contractions happen at regular intervals and increase in frequency, duration and intensity, displaying a change in cervical effacement and dilation. False labor consists of irregular contractions and very little effect, if any, on the cervix. If the patient is not having regular contractions they will be discharged home with labor instructions. (Durham & Chapman, 2014, p. 195) 2. D.H. has contractions 2 to 3 minutes apart and lasting 45 seconds. It is her third pregnancy (gravida 3, para 2002). Her bag of waters is intact at this time. She states that her due date is 2 days away. You determine that it is appropriate to ask for further information before a vaginal exam is done. What information do you need? The nurse should ask about the patient’s birthing plan. This information will provide the nurse insight to the patient’s desires and expectations regarding their childbirth options. For example, pain management, fetal monitoring, and delivery options. (Durham & Chapman, 2014, p. 206) 3. What assessment should you make to gain further information from D.H.? The nurse should perform a sterile vaginal examination as long as there is no active vaginal bleeding. This exam will provide the nurse more information regarding the cervical dilation, effacement, and fetal presentation. Results from the SVE is indicative whether or not the patient will be admitted to labor and delivery. (Durham & Chapman, 2014, p. 4. Upon examination, D.H. is 80% effaced and 4 cm dilated. The fetal heart rate (FHR) is 150 beats/min and regular. She is admitted to a labor and delivery room on the unit. What nursing measures should be done at this time? D.H.
is in the first stage of labor so it is important for the nurse to monitor intake and output; generally diet is limited oral intake to clear liquids. Emptying the bowel and bladder is important for more pelvic room, decreasing pressure and injury to urethra and bowel, and comforting the mother. The nurse should encourage walking and frequent position changes to assist with labor progression, fetal decent, and pain management. The nurse should assess for pain and treat with pharmacological and non-pharmacological strategies. The nurse should provide a safe environment and emotional and physically support to the mother and family. Also the nurse must document the admission and progression of labor. (Durham & Chapman, 2014, p. …show more content…
199) 5. As part of your assessment, you review the fetal heart strip pictured below. What will you do? The strip is an example of early deceleration. Early decelerations are seen when the uterus contracts and the fetal head is subjected to pressure that stimulates the vagal nerve. They are also a result of fetal head compression. Early decelerations are benign and require no nursing intervention. (Durham & Chapman, 2014, p. 248-249) 6. List the stages of labor. D.H. is in what stage of labor? Stage 1 – Cervical dilation; from the onset of regular contractions to full cervical dilation o Latent phase – 0-3 cm o Active phase – 4-7 cm o Transition phase – 8-10 cm Stage 2 – Complete cervical dilation (10 cm) to delivery of fetus Stage 3 – Separation and expulsion of placenta and membranes Stage 4 – Postpartum begins (Phillips Arkian et al., 2012, p. 434-435) D. H. is in stage 1 and the active phase because she is 80% effaced and 4 cm dilated. During active stage the cervix dilates form 4-7 cm with effacement of 40-80%. (Durham & Chapman, 2014, p. 199-214) 7. D.H. states that she is feeling discomfort and asks you whether there is alternative therapy available before taking medication. List at least four alternative methods to assist D.H. with controlling her discomfort. 1. Relaxation and breathing techniques – The mother in labor can take a deep breath at the beginning of the contraction to signal the onset of the contraction and then to breathe slowly during the contraction. Woman can breathe in a more rapid and shallow pattern as labor pain increases. 2. Thermal stimulation – Warmth or cold can be applied to promote comfort. Warmth can promote well-being and reduce anxiety. This causes a reduction in catecholamine production, which interferes with uterine contractility. Cold may numb the sensation of pain and release musculoskeletal pain. 3. Mental stimulation – Imagery, music, and focal points can be helpful to distract laboring mother from pain. When imagery is used the mother is instructed to think of a relaxing scene. 4. Support system – Significant other(s) and/or a doula provide emotional and physical support. Research shows that support in early pregnancy can reduce pain and complications, improve outcomes, and decrease interventions. Research has also shown that mothers that used a doula had less C-sections, decreased labors, fewer instrument deliveries, and less use of analgesia. (Durham & Chapman, 2014, p. 219-220) 8. As you assess both the mother and the fetus during the active stage of labor, you will look for abnormalities. Which of these are potential abnormalities during labor? (Select all that apply.) a. Unusual bleeding b. Brown or greenish amniotic fluid c. Contractions that last 40 to 70 seconds d. Sudden, severe pain e. Increased maternal fatigue Characteristics of the active phase of labor are cervix dilation from 4cm-7cm with effacement of 40%-80%, fetal descent continues, contractions become more intense, occurring every 2-5 minutes with duration of 45-60 seconds and discomfort increases. (Durham & Chapman, 2014, p. 208-209) CASE STUDY PROGRESS Although D.H. continues to use alternative therapies for discomfort, she asks for pain medication and receives a dose of meperidine (Demerol). Three hours later, D.H. is lying on her back, and during contractions you notice a few late decelerations of the FHR. You stay with D.H. to monitor her and her fetus and immediately call for someone to notify the PCP. 9.
Put these actions in order of priority :
2 a. Discontinue the oxytocin infusion.
1 b. Turn D.H. onto her left side and elevate her legs.
3 c. Increase the rate of the maintenance IV fluids.
4 d. Administer oxygen at 8-10 L1min by facemask.
According to Durham & Chapman, (2014), the appropriate nursing actions are aligned with the actions above in the order of B, A, C, D. It is important to change the maternal position, discontinue the oxytocin, assess hydration by giving an IV bolus, consider fetal scalp stimulation or VAS, administer O2 at 10L/min via non-rebreather face mask, consider invasive monitoring with fetal spiral electrode (FSE), support the woman and family, notify physician or midwife, plan for delivery and care of the neonate. Interventions are directed at the causes of late decelerations. (p. 251– 252)
10. Decelerations occur in an early, variable, or late pattern. What is the significance of these patterns? State what the nurse should do for each type.
The primary textbook for the course, Durham & Chapman, 2014, clearly discusses decelerations and the nursing actions for each one, they are as follows:
Early deceleration – are visually apparent, usually symmetrical with a gradual decrease and return of
FHR Associated. With an umbilical vein compression. No intervention needed usually occurs when there is fetal head compression. (p. 249) Variable deceleration – is a visually apparent abrupt decrease in the FHR. These deceleration can be periodic or episodic and vary in duration and timing in relation to UC. Nursing Actions: • Change the maternal position to promote fetal oxygenation (left side lying) • Preform SVE to evaluate cord and labor progress and preform fetal scalp stimulation • Perform amnioinfusion if ordered to increase volume of fluid in uterus to alleviate umbilical cord compression • Administer O2 at 10L/min via non-breather face mask to improve fetal oxygen status • Discontinue oxytocin • Consider need for tocolytic to reduce UCs • Consider more invasive monitoring with fetal spiral electrode • Modify pushing • Support the woman and family to reduce anxiety • Notify MD/ midwife • Plan for delivery (p. 251) Late deceleration – is a visually apparent symmetrical gradual decrease of FHR below the baseline associated with UCs. Nadir decrease 10 – 20 bpm and rarely 30 – 40 bpm. Nursing Actions: • Change the maternal position to promote fetal oxygenation • Discontinue oxytocin (consider terbutaline) to reduce uterine activity. • Assess hydration. Give an IV bolus to promote fetal oxygenation • Consider fetal scalp stimulation or VAS to assess fetal status • Administer O2 at 10L/min via non-breather face mask to improve fetal oxygen status • Consider more invasive monitoring with fetal spiral electrode • Support woman and family • Notify MD/ Midwife • Plan for delivery (p. 251 – 252) 11. As you monitor D.H., you observe for prolapse of the umbilical cord. Describe what this is and what can happen to the fetus if this occurs. Silvestri (2014) states that, prolapse of the umbilical cord is when the umbilical cord is displaced between the presenting part and the amnion or protruding through the cervix, causing compression of the cord and compromising fetal circulation. This could result in rapid deterioration in fetal perfusion and oxygenation. If fetal hypoxia is severe, violent fetal activity may occur and then cease. (p. 359) 12. What would be done if you noted that D.H. had a prolapsed cord? Steps to take if umbilical cord prolapse is suspected, according to Silvestri (2014) include: 1. Elevate the fetal presenting part that is lying on the cord by applying finger pressure with a gloved hand. 2. Place the client into extreme Trendelenburg’s or modified Sims’ position or a knee-chest position. 3. Administer oxygen 8-10 L/minute, by face mask to the client. 4. Monitor fetal heart rate and assess the fetus for hypoxia 5. Prepare to start IV fluids or increase the rate of administration of an existing solution. 6. Prepare for immediate birth 7. Document the event, actions taken, and the client’s response. The nurse should never attempt to push the cord into the uterus. If the umbilical cord is protruding from the vagina, the cord is wrapped loosely in a sterile towel with warm sterile normal saline. (p. 359) CASE STUDY PROGRESS The decelerations stop, and the remainder of the labor is uneventful; D.H. has an episiotomy to allow more room for the infant to emerge and delivers a male infant. 13. What is involved in the immediate care of the newborn? Silvestri (2014), suggests that during the immediate care of the newborn, the nurse should observe or assist with initiation of respirations, assess APGAR score, note characteristics of cry, monitor for respiratory distress, assess for cyanosis and acrocyanosis, obtain vital signs, observe the newborn for signs of hypothermia or hyperthermia and assess for gross anomalies. Specific interventions include: A. Suction the mouth first, then nares with a bulb syringe. B. Dry the newborn and stimulate crying by rubbing the back. C. Maintain temperature stability by wrapping in blankets D. Keep the newborn with the mother to facilitate bonding. E. Place the newborn at the mother’s breast if breastfeeding is planned or on the mother’s abdomen. F. Place the newborn in a radiant warmer. G. Position newborn on side to facilitate drainage of mucus. H. Ensure newborn’s proper identification I. Footprint the newborn and fingerprint the mother on the identification sheet per agency policies. Initiate other agency identification and safety procedures. J. Place matching identification bracelets on the mother and the newborn. (p. 383) 14. As you assess the newborn, you observe for CNS depressant effects that might result because the mother received an opioid during labor. Opioid antagonists such as naloxone (Narcan) can promptly reverse the CNS depressant effects in the newborn, but when is naloxone contraindicated for an infant? Regular use of opioids during pregnancy may produce withdrawal symptoms in the newborn such as irritability, excessive crying, tremors, hyperactive reflexes, fever, vomiting, diarrhea, yawning, sneezing and seizures. As the nurse it is important to obtain a medication history because some medications may be contraindicated if the client has a history of opioid dependency because these medications can lead to withdrawal symptoms in the client and newborn. (Silvestri, 2014, p. 405-406) 1 5. D.H. has her episiotomy repaired and the placenta delivered. What are the signs that the placenta has released from the uterine wall? Durham & Chapman (2014), states that signs that signify the impending delivery of the placenta include: • Upward rising of the uterus into a ball shape • Lengthening of the umbilical cord at the introitus • Sudden gush of blood from the vagina • Active management of placental delivery consists of the use of uterotonics, controlled cord traction, and uterine massage. (p. 212) 16. What assessments are important for D.H. following delivery? Durham & Chapman (2014), • Explain all procedures. • Assess the uterus for position, tone, and location, intervening with fundal massage as necessary. • Assess lochia for color, amount, and clots. • Administer medications as per orders • Assist the care provider with repair of lacerations or episiotomy • Assess maternal v/s every 15 minutes. • Monitor perineum for unusual swelling or hematoma formation. • Apply ice packs to the perineum • Assess for return of full-motor-sensory function if epidural or spinal anesthesia is used • Assess pain and medicate as per orders • Stay with the mother and family • Offer congratulations and reassurance on a job well done to the woman and family • Monitor newborn status, including T, HR, R, skin color, adequacy of peripheral circulation, type of respiration, LOC, and tone and activity every 30 minutes. • Encourage mother-baby interaction by o Providing immediate newborn contact o Assisting with early breastfeeding, if desired o Pointing out the newborn’s quiet, alert state • Monitor for bladder distention o Assist the woman to the bathroom and measure void. (p. 213) CASE STUDY OUTCOME D.H. and her newborn baby boy are taken to the maternity unit where she begins to breastfeed him. References Durham, R. F., Chapman, L. (2014). Maternal-Newborn Nursing (2nd ed.). Philadelphia, PA: F.A. Davis Company. Phillips Arkian, V., Burckhardt, J., Brown, J., & Redmske, M. (2012). The Basics. Kaplan, Inc. Silvestri, L. A. (2011). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, Mo: Elsevier/Saunders.
At the multidisciplinary meeting, the nurse will collect and assess the information provided by the other disciplines and family members stating that the patient is not at her prior level of functioning and then analyze the information to develop a diagnosis of deconditioning. Next, the nurse identifies outcomes for the patient to get stronger, achieve prior level of function, have activities of daily living (ADL’s) met in a safe environment by planning for home health, equipment, and 24/7 supervision through family or placement in a facility. This will be implemented by coordinating delivery of a walker and a 3 in 1 chair prior to discharge to daughter’s home with the home health agency nurse, physical therapist, and aide scheduled to start that day. In a week, the nurse evaluates that outcomes are being met by following up with patient, daughter, and home health agency evaluating that the patient is getting stronger, ADL’s are being met, and will soon be able to return to living independently. To achieve these standards of practice, every nurse should be aware of her own nurse practice act to ensure to be functioning with in the laws of the nurse’s state and to ensure the best outcomes and safety of the patients. In closing, it is every nurses duty to be the best nurse they are capable of being by looking at the scope of nursing practice which gives us the framework to achieve
1. What is the difference between a. and a. Which K, S, and A pertain to the care you provided to the patient you have chosen? Why do you need to be a member? K- Describe the limits and boundaries of therapeutic patient-centered care. S- Assess levels of physical and emotional comfort.
In this paper I will write about my observation of the Miss Z who was a 28 year old patient in the S hospital where I had my Lifespan 1 clinical placement. Also, I will write about Mrs. M. who is a Registered Nurse at the High Risk Pregnancy Unit of the S. hospital where Miss Z. was a patient. More specifically, I will describe how Non-Stress Test was done by the nurse Z. During this test nurse repositioned Miss Z, strapped two sensors to her belly, and interacted with Miss. Z. In the second part of my writing I will discuss two types of nursing knowledge such as Case knowledge and Patient knowledge. (Joan Liashenko, Anastasia Fisher 1999) I will describe how nurse Z incorporated these types of nursing knowledge into her encounter with Miss. Z.
...o find a balance between interventional and non-interventional birth. With this being said, I also understand that there are strict policies and protocols set in place, which I must abide to as a healthcare provider, in any birth setting. Unfortunately, these guidelines can be abused. Christiane Northrup, MD, a well recognized and respected obstetrician-gynecologist has gone as far as to tell her own daughters that they should not give birth in a hospital setting, with the safest place being home (Block, 2007, p. xxiii). Although I am not entirely against hospital births, I am a firm believe that normal, healthy pregnancies should be fully permissible to all midwives. However, high-risk pregnancies and births must remain the responsibility of skilled obstetricians. My heart’s desire is to do what is ultimately in the best interest of the mother, and her unborn child.
As Nurse Nacey Nicity began to her initial assessment on her patient, Nurse Jody McMean began to question her every mood not only in front of the other staff but also in the patient’s room. Due to the inappropriate comments made by the experienced nurse the family requested for a new nurse and for Nurse Nacey Nicity to drop their case. After Nurse Nacey Nicity handed-off, the patient she began to cry and run off the unit without speaking to anyone.
The patient is more likely to focus all their questions and concerns to the nurse. When then the
...ck to Basics: Hourly Nursing Rounds to Decrease Patient Falls and Call Light Usage and Increase Patient Satisfaction. Retrieved from http://stti.confex.com/stti/congrs08/techprogram/paper_37872.htm
A labor and delviery nurse has vast knowledge of the process and methods that are required for delivery and bring a new life into the world and is educated with the responsibilities of assiting the new born babies with their medical issues. Considering all the responsibilites needed to take on this career, such as assisting women with complications within the pregnancy, delivering a newborn and managing post birth issuses, the nurse must be professional in his or her work at all times. All people wishing to pursue the career of being a Labor and Delivery Nurse must also have good analytical skills, as part of there job to montior and analyze the mother and child (CollegeAtlas.org).
There are several levels of prioritization that nurses can use to organize their time (Lake, Moss & Duke, 2009). The first is the ABC plus V, which includes such problems as airway, cardiac or circulation, vital signs and breathing. Activities of the second level of prioritization are the ones that are immediately subsequent to those in the first level. These include untreated medical issues, mental status, acute elimination, risks, and abnormal lab results. The third level is composed of those health issues that are not included in the first two levels, including education, coping, and rest.
Nursing/Academic Edition. Web. The Web. The Web. 01 Apr 2014.
For one woman, this vision of childbirth is not the norm. Ana Rhodes is a midwife, and she is one of the only birth attendants available to...
Therefore, instruction for nursing process logs is mainly done by instructors, while charge nurses are directly responsible for instruction in nursing techniques carried out on patients, and the matter is discussed by both sides before training begins. For this case, instructors went on-site each morning and at necessary times throughout the day, making adjustments to training instruction in consultation with the charge nurse and giving training instruction. Instructors planned interim consultations with the charge nurse, confirming the direction of the nursing plan. In addition, instructors kept track of what the trainee needed to know in terms of the nursing care process by judging the trainee’s response to questions and the content of nursing logs. When one trainee was worrying about how to tailor a massage method for a patient, the trainee and the instructor took turns giving massages to the patient, prompting the trainee to think about what technique would be most
As much as working is very demanding especially as a nurse so is studying also. There are so many challenges which are involved in working and studying at the same time, some of which are: Goal, Finances, Stress, Time Management and Socialization. These challenges have both positive and negative effects on working and studying. As a matter of fact, it takes one determination and commitment to be able to combine the two at the same time and still be able to achieve ones aim.
Each of these concepts applies to the nursing process and can be theorized about extensively due to the ability to apply this theory and the concepts to a wide variety of patient
Child Birth can be a beautiful, yet unimaginable experience any mother and family member can encounter. It is a process of emotional and social involvements that make-up a natural human being. The familiarity of childbirth can play an important role in life for every individual, especially the mothers who are in labor or in delivery. Each moment during labor will become memories for the mothers to share with their grown up child in the future. Childbirth is a breath taking experience that can change someone’s life forever. The process of childbirth does not occur in a blink of an eye; in fact, it is more of a procedure that may take a few steps. Some mothers during labor, experience a severe amount of pain that medication can control and some