From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.

Maternity Case 1: Olivia Jones

Documentation Assignments

1. Document the data from your focused antepartum assessment of both Ms. Jones and the fetus.

Seizure pads were put up, and outside stimuli were minimized.

The patient reports pain 4 out 10 in the upper center of the stomach and under the right breast, and

5 out 10 right across the forehead, but reject offered pain medication.

The patient states, "My vision is blurred, and I can see some spots."

RR: 22, the patient is having difficulty breathing, and crackles can be heard at the base of both lungs.

Oxygen administration was initiated using a nonrebreathing mast at 10 L, as ordered. There is no

obvious airway obstruction. There is normal elasticity of the skin. Her skin is cool, and she is very

sweaty. Pulse is strong and regular, but the patient is tachycardic at 115 bpm. BP: 170/102 mmHg,

hypertensive. Oral temp. 37 C.

The deep tendon reflexes were very brisk, hyperreflexive, and with clonus. Graded to +4.

There is a moderate to severe pitting edema graded to +3.

The fetal heart rate was 150 beats per minute. The fetal heart rate was within normal limits.

Leopold's maneuvers were performed. The fetus is in a longitudinal lie, in vertex presentation. The

uterus tone was moderate between contractions. No contractions were noted. Fetal movement was

felt.

2. Write the situation-background-assessment-recommendation (SBAR) communications you would use

to update the provider on Ms. Jones’s status at the time of her admission.

Situation: I’m calling about Olivia Jones, a 23-year-old African American female. Gravida 1 Para 0, and

currently 36 weeks gestation. Mrs. Jones was admitted due to worsening preeclampsia symptoms for

monitoring and surveillance. The patient arrived with elevated blood pressure and nausea but did not

want to take anything for her nausea.

Background: Ms. Jones has no known allergies and no previous health conditions. She developed

preeclampsia at 30 weeks gestation.

Assessment: She is in pain of 7/10 and complaining about a headache and upper gastric pain. I am

concerned that her blood pressure is 172/102, her heart rate is 114, SpO2 of 92%. Lung auscultation

revealed crackles at bases bilaterally. DTR was very brisk, hyperreflexive, and with clonus. Graded to +4

and she has +3 pitting edema.

vSim Case 1 Olivia Jones - Documentation

Maternity Nursing Care