Jessica Wu, 35-year-old Asian female, G3 T2 P2 A0 L2, 35 weeks gestation. NKDA. Previous pregnancies uncomplicated but Cesarean births due to persistent breech position. Smoker x 15 years but states she "cut back to 3 cigarettes/day during her pregnancies." Reports that she started smoking during c...
35 weeks gestation nkda previous pregnancies uncomplicated but cesarean births due to persistent
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Swiftriver Maternity
Jessica Wu, 35-year-old Asian female, G3 T2 P2 A0 L2, 35 weeks gestation. NKDA.
Previous pregnancies uncomplicated but Cesarean births due to persistent breech
position. Smoker x 15 years but states she "cut back to 3 cigarettes/day during her
pregnancies." Reports that she started smoking during college. States started having
moderate amount of bright red bleeding about 0800. Came to the hospital after dropping
the older children at school (5 and 7 years old). She has called her husband and he is
meeting her at the hospital because he was already at work. It is now 0945. She is
anxious about the bleeding. States she "never had anything like this with her other
pregnancies!" Denies pain, contractions, or leaking of amniotic fluid. - Answer
Educational Needs- Increased
Fall Risk- Increased
Health Change- Increased
Pain Level- Normal
Psychological Needs- Increased
Psychological Needs- Normal
Kesha Jackson, Patient is a G1P0, gestational age of 33.1. She came in complaining of
contractions for 2 hours that are now every 5 mins. She is unsure about rupture of
membranes, denying vaginal bleeding and recent intercourse. She states the baby is
active. She rates her pain an 8/10. Her current vital signs are 98.1 F, 36.7 C, 92 BPM,
16 breaths/min, 122/64 mmHg, 99% on room air. The fetal heart rate is 135 baseline but
is not yet reactive. Cervical exam reveals that she is not dilated or effaced, and the
baby's head is not engaged in the pelvis. She has no medical history and NKA. In
obtaining her history, it was learned that she is 15 years old, currently homeless, and
has been staying with various friends. She does have some supplies including diapers,
wipes, and some clothing that she received from a friend. She expresses the desire to
take her baby home with her. She is receptive to teaching and assistance she just has
been unsure of how to obtain it. She came to the OB triage via a bus. - Answer
Educational Needs- Increased
Fall Risk- Increased
Health Change- Increased
Pain Level- Increased
Psychological Needs- Increased
Sensorium- Normal
Maria Sanchez, 20-year-old female, G1 P1 L1, 39 weeks gestation. Pregnancy
uncomplicated. O+, Rubella immune, Group B Strep negative. NKDA. 12-hour 1st
stage, 1 hour 2nd stage, 10 minute 3rd stage. Spontaneous vaginal delivery with 1st
degree perineal laceration one hour ago. Vital signs stable; fundus firm, midline, at
umbilicus; Lochia rubra moderate, no clots; Up to bathroom x1- 500 mL, no dysuria,
instructed on peri-care; Legs still a little "tingly" but able to bear weight with assist X2.
Pain level 3/10- ice to perineum with relief. Neonate male- Juan- 3500 g; Apgar 8 & 9; T
36.8 C, 98.2 F; AP 156 beats/minute, regular; R 52 breaths/minute, irregular. Skin-to-
, skin with mother for first hour. Beginning to show hunger cues. Their plan is do both
breast and bottle feeding; "las dos cosas." Maria's husband Raul is a quiet presence.
Her mother, grandmother, and older sister were Maria's support persons in labor. Maria
and Raul are bilingual in English and Spanish. They were both born in the US- are
Mexican Americans. Her mother speaks and understands more English than her
grandmother does. - Answer Educational: Increased
Fall Risk: Increased
Health changes: Increased
Pain Level: Increased
Psychological Needs: Increased
Sensorium: Normal
Clara Guidry, Patient is a 34 y/o G5P4 who gave birth to a 9lb. 3 oz male infant
following a 12-hour elective oxytocin induction of labor. She had an uncomplicated
labor, epidural anesthesia and a rapid second stage, no episiotomy or perineal
lacerations. Indwelling urinary catheter was removed prior to delivery. She is now one
hour postpartum and is breastfeeding her baby. An IV of 1000 mL Lactated Ringers is
infusing at KVO rate with an infusion of Lactated Ringers with oxytocin 20 Units infusing
IVPB at 125 mL/hour. Upon entering her room, she tells you that she "feels wet", and
may have urinated on herself since she is still numb from the epidural and unable to
move legs. Your assessment reveals blood pooling under buttocks onto the underpads
with numerous large clots. She is anxious, appears pale, and complains of feeling light-
headed. Her husband is at her bedside. - Answer Educational: Increased
Fall Risk: Increased
Health changes: Increased
Pain Level: Normal
Psychological Needs: Increased
Sensorium: Increased
Clara Guidry, Patient is a 34 y/o G5P4 who gave birth to a 9lb. 3 oz male infant
following a 12-hour elective oxytocin induction of labor. She had an uncomplicated
labor, epidural anesthesia and a rapid second stage, no episiotomy or perineal
lacerations. Indwelling urinary catheter was removed prior to delivery. She is now one
hour postpartum and is breastfeeding her baby. An IV of 1000 mL Lactated Ringers is
infusing at KVO rate with an infusion of Lactated Ringers with oxytocin 20 Units infusing
IVPB at 125 mL/hour. Upon entering her room, she tells you that she "feels wet", and
may have urinated on herself since she is still numb from the epidural and unable to
move legs. Your assessment reveals blood pooling under buttocks onto the underpads
with numerous large clots. She is anxious, appears pale, and complains of feeling light-
headed. Her husband is at her bedside. - Answer Physiological:
Acute Pain- False
Bleeding- True
Deficient fluid volume related to uterine atony/postpartum hemorrhage- True
Impaired Mobility- True
Impaired Patterns of Elimination- True
Ineffective tissue perfusion related to hypovolemia- True
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