NURS 320 MATERNAL NEWBORN Jennifer Humes Room 301 Jennifer Humes, 30-year-old Caucasian female, G4 T2 P0 A1 L2, 33 5/7 weeks gestation. History of chroni c hypertension and gestational hypertension with this pregnancy. Nifedipine XL 30 mg daily. NKDA. Previous pregnancies uncomplicated with NSVDs. ...
Jennifer Humes Room 301
Jennifer Humes, 30-year-old Caucasian female, G4 T2 P0 A1 L2, 33 5/7 weeks gestation. History of chronic
hypertension and gestational hypertension with this pregnancy. Nifedipine XL 30 mg daily. NKDA.
Previous pregnancies uncomplicated with NSVDs. One spontaneous abortion at 10 weeks gestation. Woke
up early morning feeling wet; wasn’t sure if leaking urine or membranes ruptured. Turned on light and it
was blood. Asked a neighbor to come over to watch other children and husband brought her to hospital.
They are making phone calls to get family member to come and take care of 5 and 2-year old children.
Anxious about this pregnancy and bleeding too. Has mild abdominal pain and contractions.
You responded correctly to 5 out of 6 evaluations:
Category Your response Explanation
Educational Needs Increased acuity Status assessment reports r/t change in condition.
Fall Risk Increased acuity Status assessment reports r/t 34 weeks gestation and pain, change in center of gravity.
Health change Increased acuity Status assessment reports r/t complication of pregnancy and bleeding.
Pain level Increased acuity Status assessment reports r/t abdominal pain and mild contractions.
Physiological Needs Increased acuity Status assessment reports r/t concern about condition and care of other children.
Sensorium Needs Normal acuity Status assessment reports no problems related to sensorium indicated in the report.
, lOMoARcPSD|3013804
Jenny Theriot Room 302
Jenny Theriot, 30 y/o G1P0 at 31 weeks’ gestation. She has had an uncomplicated pregnancy until this
morning when she woke up with clear fluid leaking from her vagina. She denies having contractions but
says she isn’t really sure what she is feeling. She presents to the Obstetrics Triage Unit, looking
distraught and crying, and says she doesn’t understand what is going on.
Your
Category response Explanation
Educational Increased Status assessment reports leaking of fluid from vagina, possible contractions and preterm delivery. These should
Needs acuity be the subject of teaching and support for the client.
Fall Risk Increased Status assessment reports the client is pregnant; this changed her center of gravity and balance.
acuity
Health change Increased Status assessment reports leaking of fluid from vagina and possible contractions.
acuity
Pain level Decrease Status assessment does not indicate report of pain.
acuity
Physiological Increased Status assessment reports leaking of fluid from vagina, possible contractions.
Needs acuity
Sensorium Normal Status assessment
Needs acuity
Kesha Jackson Room 303
, lOMoARcPSD|3013804
Kesha Jackson, Kesha Jackson 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 98.1o F., 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.
Your
Category response Explanation
Educational Increased Status Assessment reports Kesha will need a lot of education regarding preterm labor precautions, resources for
Needs acuity assistance, and caring for her baby once it arrives
Fall Risk Increased Status Assessment reports Client is at increased of fall due to changing center of gravity and balance.
acuity
Health Change Increased Status Assessment reports in addition to the pregnancy, there are now additional health issues due to the preterm
acuity labor.
Pain Level Increased Status Assessment reports she rates her pain an 8/10
acuity
Psychological Increased Status Assessment reports Kesha is homeless, is pregnant, is a teen with developing coping mechanisms, and has
Needs acuity a lack of a consistent support system.
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