NCM 107 CASE SCENARIO- HOSPITAL

Rina Lagadon is a part-time model who has come to your clinic today
October 7, 2019 for her first prenatal visit. Rina had her first menstruation
when she was 11 years old. She claims that her last menstruation was
September 8-11, 2019. She has a 3-year-old son at home born at 40 weeks
and had a miscarriage last 2018. She tells you she missed her period 4
weeks ago and immediately took a home pregnancy test. She’s happy it was
positive but also sad because she had to turn down a modeling assignment
in Paris for the summer. “I want to have a second child,” she explains, “Just
not so soon.” You suspect she’s also anxious because she says, “I know
there’s no turning back but what will a second child do to my career?” She
adds her husband, Paul, doesn’t seem a bit worried. “Is that a good thing or
not?” she asks. In addition to the positive home pregnancy test, Lauren
presents with amenorrhea, frequent urination, breast tenderness, fatigue,
and morning sickness. She’s interested in learning when she will begin to
look pregnant and what she can do for the morning sickness. Rina Lagadon
tells you she has noticed extreme mood swings since last week. She asks
you how she can reduce them. Rina’s husband Paul is also worried because
his wife sometimes has heart palpitations and often seems short of breath.
He tells the nurse, “She eats almost nothing to stay ‘model-slim.’

First prenatal visit is a time to establish baseline data relevant to Rina’s

health and identify health-promotion strategies that will be important at every
prenatal visit. Nurse Cecille gave instructions that Rina should see the doctor
for monthly prenatal visit. Rina needs to monitor her weight gain.

Mrs. Rina seems very busy with her modelling schedule for the past few
months, she returned to the clinic after 4 months due to small amount of
vaginal spotting two days ago. She claimed that she has stop her modelling
career and wants to prioritize her pregnancy. Leopold’s Maneuver was
performed and the following were noted.
• 1st Maneuver the nurse Cecille felt a hard, firm, round, and moved
independently.
• 2nd Maneuver the nurse felt small irregularities and protrusions on the
right side of the mother.
• 3rd Maneuver the nurse felt an upward movement when palpation was
done.
 • Last maneuver the nurse fingers of both hands are moved gently down
the sides of the uterus towards the pubis
• FHT is 140bpm and during the examination the nurse felt the
movement of the fetus.
• The doctor performed an IE and noticed bluish color in her vagina and
soft cervix.

Urinalysis was done and result shows proteinuria, glycosuria, and pyuria.
She was advised to continue her medication. Daily oral iron and folic
acid supplementation with 30 mg to 60 mg of elemental iron and 400 µg (0.4
mg) folic acid is recommended for pregnant women to prevent maternal
anemia, puerperal sepsis, low birth weight, and preterm birth

The time has come for Mrs. Rina to give birth. She has been having labor
contractions for 6 hours; her contractions are now 45 seconds long and 3
minutes apart having moderate- to strong-intensity contractions She tells you
she wants to have her baby “naturally” without any analgesia or anesthesia.
Her husband Paul, is on his way home but has not arrived yet. Her teenage
sister who is with her states she has no idea how to coach her, except to
pray. As you finish assessing contractions, Rina grips her abdomen,
screams, and shouts, “I’m breathing just like I’m supposed to do! Why does
this hurt so bad?” I’m afraid I will not be able to make it. She also stated that
she had been having "a lot of false labor" and hoped that this was "the real
thing". Her membranes ruptured and shows clear fluid. Mrs. Rina's
temperature 36.5, pulse 88 and respirations 22 and her blood pressure was
140/80. The fetal heart tones were 154 and regular. The nurse examined
and found that the baby's head was at +2 station, and the cervix was 6 cm.
dilated and 80 percent effaced. She reported her findings to the doctor and
the ordered Demerol 50 mg. with Phenergan 25 mg. to be given
intravenously when needed. At 8:05 urge to defecate with descent of the
presenting part was evident and complete dilatation of the cervix was evident
on vaginal examination

The doctor did a midline episiotomy. At 8:08 p.m. Mrs. M. gave birth to
a 6.2 lbs., (2.818 kg.) boy in the R.O.A. position. The nurse put medicine in
the baby's eyes and placed an identifying bracelet on his right wrist and
ankle. A matching bracelet was placed on the mother's wrist. The baby was
placed on Rina’s breast to initiate breastfeeding. Oxytocin was given. There
was sudden gush of blood and lengthening of the cord and at 8:15 p.m. the
placenta was expelled and upon checking cotyledons are all complete.

Mrs. Rina has not voided since she gave birth. Although her baby latches
well, Mrs. Rina is worried she’s not getting enough breast milk. She tells you,
“I haven’t smoked in 9 months. Can’t wait to go home so I can light up.” Paul
pulls you aside and says, “Sometimes, I see my wife crying for no reason.
Why does she get so upset over little things? Isn’t she as happy as I am?”

At the OB was she was observed for profuse bleeding or any untoward
signs and symptoms felt. The nurse upon checking noted that Mrs Rina’s
bleeding is more than 500ml. Frequent change of sanitary napkins were
noted. Lochia is bright red. Uterus was at the midline, relax and not firm.
Occasional uterine cramping was also noted. On palpation, a full bladder is
felt as a hard or firm area just above the symphysis pubis. Mrs. Rina reports
of diaphoresis and excessive thirst. Pain in the suture site was reported.
Stitches are present, the suture line is 1 or 2 inches long. Mrs. Rina feels thirsty
and hungry but can not avail due to exhaustion after the delivery. She said
she feels too weak to do things for herself. Hemoglobin finding is lower than
8.5 g/100 ml. Distended rectal veins where noted. Bowel sounds are active,
but no passage of stool was reported. Mrs. Rina also reports that she is
unable to sleep or have rest.