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Maternity Case 1 Olivia Jones Documentation Assignments
Course: Fundamentals Of Nursing (NUR121)
28 Documents
Students shared 28 documents in this course
University: County College of Morris
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Maternity Case 1: Olivia Jones Documentation Assignments
1. Please document the data that you have collected from your focused antepartum assessment of
both Ms. Jones and the fetus.
During the assessment, Ms. Jones reported experiencing pain rated at 5/10, which was located in the
upper center of the stomach and under the right breast, as well as across her forehead. Although she
rejected the offered pain medication, she expressed difficulty breathing and noted blurred vision, seeing
spots in her field of vision. The respiratory rate was recorded at 22 breaths per minute, and O2
nonrebreathing mask was administered at 10 L as ordered. The lungs sound revealed crackles at both
bases. The pulse was strong and regular, measuring at 115 per minute, while blood pressure was high at
170/102 mmHg. The patient's temperature was taken orally and recorded as 37 degrees Celsius. Ms.
Jones showed very brisk, hyper-reflexive deep tendon reflexes and clonus graded to +4. Additionally,
moderate to severe pitting edema was present and graded at +3. Fetal heart rate (FHR) was recorded at
150 beats per minute, and the uterus tone was moderate between contractions. No contractions were
noted, but the fetal movement was felt. Leopold's maneuvers were conducted, revealing that the fetus
was in a longitudinal lie, in vertex presentation. Her skin was cool, but she was sweating profusely. The IV
site had no redness, swelling, infiltration, bleeding, or drainage. The dressing was dry and intact.
2. Write the SBAR communication that you would use to update the provider on Ms. Jones's status
at the time of her admission.
Olivia Jones is a 23-year-old African-American female who is a G1P0 at 36 weeks of gestation. She has
been diagnosed with severe preeclampsia and was admitted to the labor and delivery unit for further
assessment and surveillance. Ms. Jones has no known allergies, and her pregnancy has been
unremarkable until her routine prenatal visit at 30 weeks, during which her blood pressure was elevated
at 146/92 mm Hg, and she had proteinuria, and developing mild preeclampsia. Since then, she has been
on bed rest at home until today's prenatal visit, which was marked by increasing symptoms that led to
her admission. Over the past week, she has gained three pounds. During the antepartum assessment,
Ms. Jones tested positive for protein dipstick with a score of +4, while ketones and glucose tested
negative. Dependent edema scored at +2, and facial puffiness was also present. The patient is currently
complaining of a headache that is not relieved by acetaminophen, as well as nausea, fatigue, epigastric
pain, visual changes, and chest tightness. Although the fetus is active, the patient reported that it is
quieter than usual.
In summary, during the antepartum assessment, Ms. Jones's respiratory rate was 22 breaths per minute,
and she was administered O2 nonrebreathing mask 10 L as ordered. The lungs sound revealed crackles
at both bases. Her pulse was strong and regular, measuring at 115 per minute, while blood pressure was
high at 170/102 mmHg. Her temperature was 37 degrees Celsius. The patient showed very brisk, hyper-
reflexive deep tendon reflexes and clonus graded to +4. Moderate to severe pitting edema was present
and graded at +3. Fetal heart rate (FHR) was recorded at 150 beats per minute, and the uterus tone was
moderate between contractions. No contractions were noted, but fetal movement was felt. Leopold's
maneuvers were conducted, revealing that the fetus was in a longitudinal lie, in vertex presentation. Her
skin was cool, but she was sweating profusely. The IV site had no redness, swelling, infiltration, bleeding,
or drainage. The dressing was dry and intact.
