Maternity Case 4: Carla Hernandez (Intrapartum - Active Labor)

Documentation Assignments– Document in your own words.

1.Document your initial assessment data for Carla Hernandez, including fetal heart rate
activity (baseline fetal heart rate, long-term variability, accelerations, and decelerations) and
maternal vital signs.
Carla Hernandez is a 32-year-old Hispanic female, G2P1 (L1), at 39 5/7 weeks gestation. She was admitted
to labor and delivery in active labor at 0600 hours today, accompanied by her husband Earl. To progress the
delivery, artificial rupture of membranes was performed by the provider a few minutes ago. The provider has
just left the room to make rounds. Suddenly the fetal heart rate drops dramatically, and you discover that the
umbilical cord is prolapsed. You are ready to handle this situation with another nurse who is also present in
theroom. 0010: Baseline FHR- 89, Maternal HR 89, BP 136/82, RR 16. She is conscious, SpO2 97%,
Temp 99 degrees F.

2. Document the medication(s) that you administered.

0054: Gave patient 100% oxygen from a non-rebreathing mask.0359: Administered 0.25 mg of terbutaline
subcutaneously.

3. Document the time that the umbilical cord prolapsed during this simulation and the nursing
interventions that were taken, including the timing. Note an evaluation of the effectiveness of these
measures in resolving the problem identified, and the times that the provider was notified.
Umbilical Cord Prolapsed at 0720 and I administered 500 mL bolus of LR IV given over 30minutes 0721
and oxygen per non-rebreather 0721. I relieved pressure from the umbilical cord and assisted patient into
Trendelenberg position at 0722. I called the provider at 0722. FHR raised from 71 to 105.

4. Document the fetal heart rate monitoring and any abnormalities.

FHR 71 and EFM is showing a non-reassuring drop in FHR late decelerations as indication of prolapse.

5. Record the communication that was expressed to Carla Hernandez’s husband, Earl
I explained to Earl that a C-section delivery is needed because blood flow through the umbilical cord is
not getting enough oxygen to the baby. And I ask him if he has any questions and how he is feeling.
6.Document how the health care team worked together during this simulation and state your
recommendations for improvement.I called NICU for assistance, Surgery to prep a room, and the
Provider as soon as I implemented interventions with the help of another nurse.

Nurses note
Carla Hernandez
Jasmyn Gould (SN)
32 y/o, HF, G2P1 (L1), @ 39 5/7 wks. Of gestation. ADMIT. to L&D in active labor on 6/25/20,
w/husband Earl. HCP broke water. EFM: non-reassuring drop in FHR late deceleration as indication off
prolapse shortly after. Maternal VS: WNL, pain 2/10. NRM, 10L via applied. Performed pelvic exam,
relieved pressure to cord, assisted mom to Trendelenburg position. ADMIN. Drugs as order.
Notified HCP. ADMIN. New meds STAT. per MAR. Edu. and comfort pt./husband. Witnessed informed
consent sign. Contacted: surgery, anesthesia, and NICU. Maternal VS: WNL. FHR raised from 71 to 105.
Continued monitoring maternal and FHR until Handoff to surgery.