Maternity Case 1: Olivia Jones

Documentation Assignments

Ayleen Vasquez

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

I assessed the patient from head to toe. Monitored the patient’s vital signs and applied oxygen via non-

rebreather mask at 10L. I attached the Fetal heart monitor to monitor the fetus. Minimized outside

stimulation by removed vistors and dimmed the lights. I made sure she had seizure pads and suction

for seizure precautions. Inserted a foley catheter.

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.

Olivia Jones, a 23 year old African American female, G1P0 is at 36 weeks gestation. She was admitted to

the labor and delivery department. During her assessment at 30 weeks, she had an elevated blood

pressure of 146/92, proteinuria and mild case of preeclampsia. When they assessed her when she

was admitted to L&D, she had a protein dipstick of +4, negative ketones and glucose, +2 dependent

edema, and puffiness in the face. Some of the manifestations she was experiencing were nausea,

fatigue, and heaches. I would recommend to speak to the provider about her experiencing issues and

suggest she may need to be induced to make sure her preeclampsia does not get worse.

3. Document the teaching you would provide to the patient and her support person prior to

administering magnesium sulfate.

Asked patient if she had any allergies to any medications. Educated the family and patient before

administering magnesium sulfate. Made sure they understood that it is used to prevent seizures in

severe preeclampsia. They would need to be put on their side and should not be in a semi-fowler’s

position for long periods of time. If she feels like she is contracting or passing out to let the provider

know. We will monitor vitals to make sure they are stable.

4. Document the administration of the magnesium sulfate bolus and the initiation of the magnesium

sulfate infusion.

Infused magnesium sulfate in sterile water (6g in 100 mL) at 200 mL/hr.

5. Document your reassessment of the patient’s status after administering magnesium sulfate.

After administering magnesium sulfate, I assessed Ms. Jones. Her respirations were at 22 breaths/min.

Chest moves bilaterally equal. Pulses are bilaterally strong at 100 bpm and regular. Blood pressure

was 166/100 mmHg. Her temperature was at 98.6F.

Olivia Jones - Vsim documentation

NUR1211 (NUR1211)