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Olivia Jones. Maternity Case 1 DA

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Course

Fundamental of Nursing (NUR 101)

96 Documents
Students shared 96 documents in this course
Academic year: 2020/2021
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Nassau Community College
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Maternity Case 1: Olivia Jones

Documentation Assignments

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

    • The patient’s vitals are; HR: 225, Pulse: Present, BP: 170/101, Respirations: 22 beats/min, sP02%: 92%, TEMP: 37c. Deep tendon reflex: +4 with clonus. Pitting edema: + Normal bowel sounds, Heart sounds were regular without murmur, lung sounds had crackles at both bases. Patient had cough, shortness of breath, fatigue and nausea. Patient complained of having a headache, refused medication to treat headache.
    • Fetal Vitals are; HR: 170 beats per minute. The fetus was tachycardic. Fetus is longitudinal lie and vertex presentation

  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.

S- Hello, im calling in regards to Olivia Jones, She is complaining of nausea headache of 5/10 not resolved by acetaminophen and visual disturbances. She is currently on strict bedrest.

B- Olivia Jones is a 23 year old female, G1P0 at 36 weeks of gestation. She is diagnosed with severe preeclampsia.

A – Vitals BP 167/100, Res: 22, HR: 225, Pulse: Present, BP: 170/101, Respirations: 22 beats/min,

sP02%: 92%, TEMP: 37c. Deep tendon reflex: +4 with clonus. Pitting edema: +3.

R – Can I get an order to manage her hypertensive state.

  1. Document the teaching you would provide to the patient and her support person prior to administering magnesium sulfate. Prior to the administration of magnesium sulfate, I would educate the patient that magnesium sulfate is used to prevent seizures in preeclampsia, a condition caused by high blood pressure and protein in the urine. Preeclampsia is a life threatening complications that can occur during pregnancy.

  2. Document the administration of the magnesium sulfate bolus and the initiation of the magnesium sulfate infusion. IV magnesium sulphate in sterile water (6g in 100 ml) at 200 ml/hr was started. Followed by an infusion of magnesium sulface 20g in 500 ml of sterile water at 50ml/hr

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

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

After administering magnesium sulfate, the fetal heart rate was 150 beats per minutes, within normal limits. The patient continued to have nausea and epigastric pain. He BP drpped to 166/100 mm/Hg. Res:

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

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Olivia Jones. Maternity Case 1 DA

Course: Fundamental of Nursing (NUR 101)

96 Documents
Students shared 96 documents in this course

University: Nassau Community College

Was this document helpful?
Maternity Case 1: Olivia Jones
Documentation Assignments
1. Document the data from your focused antepartum assessment of both Ms. Jones and the fetus.
- The patient’s vitals are; HR: 225, Pulse: Present, BP: 170/101, Respirations: 22 beats/min,
sP02%: 92%, TEMP: 37c. Deep tendon reflex: +4 with clonus. Pitting edema: +3
Normal bowel sounds, Heart sounds were regular without murmur, lung sounds had crackles at
both bases. Patient had cough, shortness of breath, fatigue and nausea.
Patient complained of having a headache, refused medication to treat headache.
- Fetal Vitals are; HR: 170 beats per minute. The fetus was tachycardic. Fetus is longitudinal lie
and vertex presentation
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.
S- Hello, im calling in regards to Olivia Jones, She is complaining of nausea headache of 5/10 not resolved
by acetaminophen and visual disturbances. She is currently on strict bedrest.
B- Olivia Jones is a 23 year old female, G1P0 at 36 weeks of gestation. She is diagnosed with severe
preeclampsia.
A – Vitals BP 167/100, Res: 22, HR: 225, Pulse: Present, BP: 170/101, Respirations: 22 beats/min,
sP02%: 92%, TEMP: 37c. Deep tendon reflex: +4 with clonus. Pitting edema: +3.
R – Can I get an order to manage her hypertensive state.
3. Document the teaching you would provide to the patient and her support person prior to
administering magnesium sulfate.
Prior to the administration of magnesium sulfate, I would educate the patient that magnesium
sulfate is used to prevent seizures in preeclampsia, a condition caused by high blood pressure
and protein in the urine. Preeclampsia is a life threatening complications that can occur during
pregnancy.
4. Document the administration of the magnesium sulfate bolus and the initiation of the
magnesium sulfate infusion.
IV magnesium sulphate in sterile water (6g in 100 ml) at 200 ml/hr was started. Followed by an
infusion of magnesium sulface 20g in 500 ml of sterile water at 50ml/hr
5. Document your reassessment of the patient’s status after administering magnesium sulfate.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.

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