COMPLICATED CASE STUDY

Scenario

1. D.H. Is a 34-year-old multigravida patient who wants to use the Basal Body Temperature method of the Fertility Awareness methods of birth control because she is “becoming older” and wants a less invasive method of birth control. D.H. desires more information about Basal Body Temperature method of birth control. Explain BBT method of birth control to include indications, reliability, risks, benefits, and how to use this method.

Some women used the basal body temperature method as a form of birth control, and the way to do this is by using a thermometer to measure the basal body temperature the same route and the same time each day. The patient will avoid sex when the temperature increase ½ a degree, indicating that they are ovulating. This is beneficial because there are no pharmacological side effects. This can prove to be ineffective if a woman has an irregular period, or other factor such as stress or medications throw off their basal body temperature.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

2. D.H. at 37 years old comes to the clinic stating, “I think I may be pregnant. I haven’t had a period in 10 weeks, my breasts are tingling, and I don’t fit into my jeans.” Based upon this information, what type of Signs of Pregnancy is this client experiencing?

The signs of pregnancy that the client is experiencing are called presumptive signs of pregnancy. These signs are only felt by the patient and can not be observed by others such as the missed period and the tingling of breast.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

3. This is her fifth pregnancy. She has two children 8 and 3 at home both term deliveries (still living). Other pregnancies were spontaneous abortions. What is the GP and GTPAL based upon her maternal history?

Rationale: This is the patient’s 5 pregnancy, she has had 2 termed deliveries, 0 preterm deliveries, 2 spontaneous abortions, and 2 living children at home.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

4. An ultrasound is done at the initial visit and confirms that the client is 7 weeks pregnant. What type of ultrasound was performed (using the number of weeks as a guide to determine the appropriate type)?

The type of ultrasound that should be done is a transvaginal ultrasound.

Rationale: The transvaginal ultrasound should be used because it determines the gestational age of the fetus during the first trimester of pregnancy and D.H is 7 weeks pregnant which makes this ultrasound appropriate for her to use.

a. What instructions would have been given to the client prior to the ultrasound being performed?

The client should drink plenty of fluids before the exam and avoid voiding before the examination, the rationale behind this is that it allows for better visualization of the fetus during the ultrasound.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

5. The client states that her last period began on 2 March. Using Naegel’s rule, what is the expected date of delivery?

The patient’s delivery date is December 9th

Rationale: Using the Naegele’s method minus 3 months from the month of the last menstrual cycle and add 7 days and then adjust the year.

6. D.H. has an uneventful perinatal history. Then, at her 38 week prenatal appointment the nurse assesses the following: weight 176 lbs (increase of 10 lbs in one week); swelling in her hands, feet, and face; edema +2; blood pressure of 142/94 mmHg; pulse 88 bpm; edema +2; deep tendon reflexes +2; no clonus; proteinuria +2 (on urine dip); negative urine glucose; frontal headache with eases with acetaminophen. She states the light is too bright while shielding her eyes. What other questions should a nurse ask the patient at this time?

A pain assessment should be completed, rating it on the number scale and then following the PQRST tool for assessing pain. Some other important questions that the client should be asked is if she haves been having any problems with her vision and any signs of confusion. The patient should report nausea and vomiting, difficult breathing, epigastric pain and fatigue.

Rationale: Frontal headaches are associated with preeclampsia as well as proteinuria and edema. The client experiences the swelling because of the rapid weight gain hypertension. The hyperreflexia and vision changes may indicate that D. H is prone to seizures.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

7. What laboratory values should be considered at this time?

The labs to be considered are LFTS, Creatinine levels, CBC, and platelet counts.

Rationale: D.H is experiencing hypotension and proteinuria, acute kidney failure can occur, increased platelet counts can LFTs to evaluate liver function and recognize sign for thrombocytopenia.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

8. What are the risk factors for preeclampsia (all of them)? Identify the risk factors that this patient has for preeclampsia?

Some risk factors are women with a family history of preeclampsia, hypertension, overweight, pregnant with multiple fetuses, first pregnancy, and ages under 19 and over 40 are more at risk.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

9. What are three possible complications with preeclampsia?

Three complications for preeclampsia are organ damage, placental abruption, and decrease oxygen to the baby.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

10. Write the priority physiologic nursing diagnosis for this client (what is the most important safety need)? Write a goal for this diagnosis.

Fluid volume overload related to fluid shift from vascular to interstitial compartments evidence by + 2 edema.

Goal: Patient’s blood pressure will be reduced from 142/94mmHg to 120/80 mmHg within the next 2 hours.

The most important safety needs are the reduce the blood pressure promoting increase blood flow to the baby, result in better oxygen saturation and preventing premature labor.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

11. D.H. is admitted to labor and delivery for a labor induction with pitocin. Describe the procedure for pitocin induction.

a. What are the nursing responsibilities for safe administration of pitocin?

Monitor uterine contractions

Monitor client’s blood pressure

Monitor FHR

Rationale: Pitocin can increase contractions and fetus may not tolerate well so there might be a need to reduce pitocin or discontinue. Pitocin can cause decrease oxygen saturation to the fetus and can also cause late decelerations.

b. What are three potential complications?

Placental abruption

Uterine rupture

Seizures

Rationale: These can occur due to decrease oxygenation in the uterus and the placenta, leading to hypoxia and ischemia.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

12. D.H. complains of increasing headache, proteinuria is +3, and DTR’s are +3. Vital signs include Bp 154/94 mmHg, pulse 92. What is the primary concern based upon this assessment?

These signs and symptoms can suggest that a seizure is about to occur.

Rationale: hyperreflexia, hypertension, and headache are signs of worsening preeclampsia and if untreated will lead to seizure.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

13. The physician orders magnesium sulfate infusion 4-gram bolus over 30 minutes, then 2 gm per hour. The pharmacy sends up an IV bag of 1-liter Lactated Ringers with 40 mg magnesium sulfate for a secondary line. Describe the procedure for magnesium sulfate infusion.

a. What is the purpose for administering this medication?

Magnesium sulfate is a n anticonvulsant medication used to prevent or treat seizures in patient with preeclampsia.

b. At what rate will the bolus be administered in mL/hr?

200 mL per hour

Describe the adverse effects of magnesium sulfate administration.

c. Some adverse effects are decreased respirations, flushing, sweating, confusion hypotension and decreased deep tendon reflex.

d. What are the nursing responsibilities for safe administration of MgSO4?

The nurse should monitor the patient’s respirations making sure that they stay above 14 breaths per minute, monitor the client’s blood pressure, and have a crash cart ready with calcium gluconate.

Rationale: bradypnea and hypotension can be a sign of magnesium toxicity and therefore a crash cart should be ready if the patient starts to experience toxicity, the drug calcium gluconate is a reversal agent for magnesium.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

14. D.H. is being induced for labor for the past 2 hours and her cervix is 5 cm/ 80%/ 0 station. Membranes are ruptured for one hour of light yellow, colored amniotic fluid.

15. Review the stages of labor. What stage is D.H. in at this time based on the above information?

The first stage of labor is when thinning (effacement) and dilation of the cervix occur. This will start with 1 centimeter of dilation and increase to 10 centimeters. The first stage of labor has three parts, early labor, active labor, and transition to second stage. In ear labor the cervix dilates to 4 centimeters and contraction becomes stronger and more intense. In active labor the cervix dilates about 4 to 7 centimeters with contractions occurring every 3 to 4 minutes lasting about 60 seconds. If the membrane ruptures during this phase the contractions will speed up. In transition to the second stage the cervix dilates to 7 to 10 centimeters and contraction last about 60 to 90 seconds and occur every 2 to 3 minutes. The patient may feel exhausted and have little time to rest.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

The second stage of labor is when the cervix if fully dilated and the baby starts to move through the birth canal. The patient can start to push and the phase of labor ends with the birth of the baby.

The third stage of labor is after the birth of the baby and the uterus continues to contract to push out the placenta with 5 to 15 minutes after the baby is born.

The fourth stage of labor is the recovery phase where the nurse will assist the patient to help the uterus to contract and decrease bleeding.

Rationale: D. H is in the first stage of labor and she is also in active labor because she is 5 centimeters dilated with 80% effacement.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

16. The obstetrician orders internal monitoring of the fetal heart rate and placement of an intrauterine pressure catheter to monitor contractions. Below is the tracing after 30 minutes of monitoring.

a. What is the FHR?

130 beats per minute

b. Describe the variability.

The variability is moderation and the rationale behind this is that the amplitude ranges between 6 to 25 bpm.

c. If there are any decelerations, what type is present?

Yes, there are late decelerations because they are lasting more than 30 seconds.

d. The type of deceleration is What is the frequency of contractions? The frequency of the contractions are about 1 to 2 minutes, the rationale behind this is that each box counts as 10 seconds.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

17. What are the most appropriate nursing interventions at this time?

The most appropriate interventions at this time would be maternal repositioning, placing at least 2 liters of oxygen on the patient, and iv fluid bolus.

Changing the client’s position to promote uteroplacental blood flow, also promoting fetal descent.

Rationale: Increased uterine contraction decreased oxygen saturation ad decreases blood flow to the uterus. Iv fluid bolus can correct maternal hypotension and repositioning the client can ease discomfort and promote more blood flow to the fetus decreasing the late decelerations.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

18. If calling the physician was on the list of appropriate nursing interventions, write out an SBAR to the physician at this time.

I- D.H is a multigravida G5P2 client who is 38 weeks pregnant

S- client is G5, T2, P0, A2, L2, and is showing signs of possible preeclampsia, she was induced by pitocin, is in the first stage of labor, at 5 cm dilated/80%/0

B- client was induced on pitocin and ruptured 2 hours ago with the amniotic fluid of light yellow color

A- FHR baseline is at 130 bpm with moderate variability and late decelerations, contractions 1-2 minutes apart.

R- I would recommend discontinuing the oxytocin(pitocin) and administering iv fluid bolus to client to prevent maternal hypotension.

Rationale: The pitocin is causing late deceleration in the fetus and the IV bolus will prevent maternal hypotension.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

19. D.H. elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, what is the nurse’s priority action?

a. Checking for cervical dilation

b. Placing the client in a supine position

c. Checking the client’s blood pressure

d. Obtaining a fetal heart rate

Following the start of an epidural anesthesia, the priority action would be to monitor the client’s blood pressure.

Rationale: Epidural anesthesia can cause maternal hypotension because the sympathetic nerves are blocked, and this results in vasodilation and hypotension. The fetal heartrate should already be on monitor and according to Murray, McKinney, Holub, & Jones, the maternal blood pressure and fetal heart rate should be assessed every 5 minutes during the first 15 minutes after the initiation of the epidural anesthesia has been administered (Murray, McKinney, Holub, & Jones, 2019).

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

20. D.H. delivers via a cesarean section 2 hours later an 8-pound 8-ounce girl, with APGAR of 4 and 8 and the infant is transferred to the nursery.

21. Describe the immediate newborn care for the first hour of infant life.

The newborn should be cord clumping, then the baby should be dried off right away and then be placed in the warmer. Then the newborn should be assessed using the APGAR score test, and then skin-to-skin with the mother or parents, breast feeding should be initiated at this point.

Rationale: The newborn should be dried shortly after birth because they lack mechanism to stay warm. The newborns loose heat through evaporation so they should be dried off and placed in the warmer with a hat on the head. APGAR should be assessed so that we know that the baby’s heart rate is within range and they have adequate circulation of blood. Also, we should check their muscle and that their reflexes are intact. Skin-to-skin is important for mother and baby to bond and this also stabilizes the baby’s temperature. Breast feeding promotes or strengthens the sucking reflex and provides protection for the baby from infection and reduces the risk of hyperbilirubinemia.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4458502/

Postpartum Focus

22. D. H. is transferred to the postpartum unit after recovering from surgery. Magnesium sulfate is infusing at 2 gm/hr piggybacked into her mainline of normal saline. In a secondary sight, pitocin is infusing. She has received pain medications. What are the nurse’s priority assessments for this patient?

Priority assessment for the nurse is to monitor respirations since magnesium sulfate is ahigh alert drug. Hospital protocol states that respirations should not be below 14 per minute. The nurse should monitor vital signs and labs. Both Pitocin and magnesium sulfate can decrease the client’s blood pressure, the vital sign should be monitored frequently with reversal drug readily available

Rationale: Magnesium toxicity can cause respirations blew 12 breaths per minute, O2 SAT less than 95%, hypotension which can come from both the Pitocin and the magnesium sulfate. Calcium Gluconate should be available to reverse the effects of me=magnesium sulfate.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

23. A boggy uterine fundus is noted upon assessment. Write the priority nursing diagnosis for D.H at this time.

Risk for post-partum hemorrhage evidence by excessive bleeding related to boggy fundus.

Rationale: The priority at this time is the patient’s risk for post-partum hemorrhaging, which is why the nurse will need to message the fundus right away to firm it and decrease bleeding, this will lower the patient’s risk for hemorrhaging.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

a. What is the goal for this diagnosis? Patient will have firm fundus and reduced blood loss less than 200 ml by the end of shift.

b. Include three nursing interventions that will resolve or relieve the problems with rationale.

1.) Message fundus to stimulate contraction and firm the uterus resulting in reduced blood loss.

2.) Monitor blood pressure to determine the extent of blood loss

3.) Monitor hemoglobin and hematocrit to determine the need for blood transfusion

c. What additional medication and method of delivery can be anticipated at this time? Oxytocin (Pitocin) contains vasoactive and antidiuretic properties that helps to maintain firm uterine contractions after birth to control post-partum bleeding.

Rationale: messaging the fundus stimulates contraction in the uterus, this reduced blood loss, if the patient is hypotensive, then blood loss is severe and patient is at risk for fluid volume deficit or hypovolemia, if H&H is low the client will need a blood transfusion, this show that they are loosing lots of blood and passing huge clots, all of these signs and symptom identify with postpartum hemorrhage

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

Newborn Focus

25. The infant at 1 hour of age is without respiratory distress and has been assessed with the New Ballard Score. The infant is determined to be LGA. What does this mean? What plan of care would a nurse develop to best care for this infant?

Considering the baby’s weight, length, and head circumference will help to determine if the baby is LGA, if those measurements are in the 90th percentile. Macrosomia, which means large body is used to diagnosis a baby weighing more than 8 lbs. and 13oz. The plan of care for this baby is to monitor the glucose levels and assess for signs and symptoms of hyperbilirubinemia and encourage breast feeding.

Rationale: The nurse should monitor and assess the baby for signs and symptom of hypoglycemia because after birth, the supply of glucose from the mother is no longer available and the baby may continue to produce high amounts of insulin. It is important for the nurse to monitor the baby’s glucose and by encouraging breast feeding, the mother can help to prevent a rise in blood sugar in her infant and help excrete bilirubin.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4458502/

26. Explain to the father of the baby about the medications that the baby will receive upon admission to the nursery.

The medications that the baby will receive upon admission to the nursery are vitamin K, Erythromycin Ophthalmic Ointment, and Hepatitis B Vaccine.

Rational: The vitamin K is needed to produce the clotting factors the prevent the newborn from bleeding since newborn liver may not be mature enough to store vitamin K and the intestine is not able to synthesize Vitamin K yet. The Erythromycin Ophthalmic Ointment is to protect the newborn’s eye from any harmful bacteria that might be present in the mother’s birth canal. The hepatitis B vaccine is to protect the newborn from hepatitis if the mom carries the virus and so this vaccine provides immunity.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

27. The mother plans to breastfeed and can express colostrum. Describe the benefits of colostrum.

Colostrum contains antibodies, which benefits the baby because it helps to build up their immune system. Colostrum coats the baby’s stomach and intestines to prevent disease from germs and helps the baby form meconium.

Rationale: The baby needs to defecate and urinate to pass waste products. Colostrum is the baby’s first meal which is packed with plenty of nutrients and this also strengthens the newborn’s immune system.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4458502/

28. A student nurse asks, “When will the milk come in?” Explain to the student the process of milk production and information about lactation that the mother will need to know.

Milk production is influenced by postpartum hormones and this starts on the 3 or 4 day after birth. Prolactin begin milk production, the posterior pituitary hormone Oxytocin cause the let-down reflex or makes the muscles around the milk-producing glands contracts, which make the breast feel full and heavy.

Rationale: The milk is colostrum which develops into mature milk, prolactin and oxytocin begins milk production and muscle contraction to start heavy milk flow by the 3 or 4 day.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

29. On the day of discharge, the infant’s skin color is yellow colored down to the chest area. A bilirubin level drawn in the morning was 8 dl. Describe the discharge instructions that should be given to the parents regarding this condition. (Start with what the condition is called.)

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4458502/

30. On the day of discharge the infant is taken to the nursery for the Universal Newborn Screening and Newborn Hearing Screening. Explain to the parents the reason these are done.

These tests are done to detect critical conditions such as congenital heart defects, metabolic, hematologic, and genetic disorders that may not surface right after birth. The hearing screening is important because it helps prevent developmental delays and improve communication skills.

Rationale: The hearing screening important because according to Murray, McKinney, Holub, & Jones, about 12,000 infants are born in the united states with hearing impairment, making hearing impairment the most common congenital abnormalities in newborn. Again, these tests are important because some of the signs and symptoms may not surface within the 24 hours of delivery.

Reference: Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

Reference

Murray, S. S., McKinney, E.S., Holub, K.s& Jones, R. (2019). Foundations of maternal-newborn and women’s health nursing (7th ed.). St. Louis, MO: Elsevier.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4458502/