Maternal Newborn Case Study Approach

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Maternal Newborn
Med Surg 2 (West Coast University)
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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.

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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 be
Needs acuity 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

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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
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 a
Needs acuity lack of a consistent support system.
Sensorium Normal Status Assessment reports no issues reported here.
acuity

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Saftey
Your
Description Response Explanation
Fall Risk True Status assessment reports Client is pregnant with a changing center of gravity
and balance, increasing risk for falls.
Ineffective health True Status assessment reports Client has limited resources and several barriers to
maintenance health and healthcare.
Infection False Status assessment reports no signs of infection noted.
Knowledge Deficit True Status assessment reports Client does require teaching about resources,
childcare and preterm labor plan of care.
Psychological
Your
Anxiety False No indication
Impaired home True Status assessment reports Client is currently homeless and with limited
maintenance resources.
Noncompliance False Status assessment reports she has been complaint and is willing to learn and
perform the necessary steps to get help.
Risk for impaired True Status assessment reports Kesha has limited resources and is an adolescent
parenting without a strong support system.
Physiological

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Your
Respons
Description e Explanation
Acute Pain True Status assessment rates pain 8/10
Decreased cardiac False Status assessment reports status does not reflect issues with cardiac output at this
output time.
Impared Mobility False Status assessment reports No mobility issues have been identified.
Nausea False Status assessment reports No reports of nausea.
Risk for nutritional True Status assessment reports adolescents who are pregnant are at higher risk for
imbalance nutritional deficiencies due to supporting their growth as well as fetal growth.
Scenario 1
Your
orde Correc
r t order Step Explanation
4 1 Assure that the monitor It is important to make sure that you are tracing FHR and not maternal, and
is tracing fetal heart that the tracing is consistent. There could be accels that are not showing up
rate consistently. due to an inconsistent or interrupted tracing.
3 2 Adjust fetal heart rate Adjusting FHR monitor can allow for clearer tracing and may also stimulate
monitor. the fetus which might aid in obtaining accelerations.
1 3 Give mother some cold Cold, sugary drinks will often increase fetal heart rate and activity. It is
juice to drink. important to have already established a good tracing.
2 4 Reposition mother to Repositioning mother results in fetal repositioning which may increase
left lateral position. accelerations. However, it often makes tracing more difficult so should not
be done before other easier and more efficient interventions.
5 5 Request ultrasound for A biophysical profile can assess overall fetal status if NST is not reactive or
biophysical profile. tracing is difficult to maintain/other interventions to obtain NST ineffective.
It is more time consuming and expensive so should not be used before
other interventions.

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Scenario 2
Your
orde Correc
r t order Step Explanation
1 1 Assess FHR and contraction The presence of contractions is an indicator of preterm labor. It is
pattern per monitor. important to assess the frequency and intensity of contractions. It is
always imperative to monitor FHR status to assess fetus.
2 2 Perform sterile cervical exam A sterile cervical exam will reveal how advanced the preterm labor is.
to determine dilation, If significant cervical change is present, magnesium sulfate for
effacement, and station. neuroprotection and tocolysis should be considered.
4 3 Obtain urinalysis and lab Obtaining Urinalysis and lab work can point to potential causes for
work such as CBC. preterm labor such as dehydration or infection. This will guide your
treatment.
3 4 Administer IV fluids and/or Administering fluids and/or antibiotics would be determined after an
antibiotics. assessment and lab work have been completed and have pointed to a
potential cause.
5 5 Consider administration of Tocolytics should be considered if other interventions have failed.
tocolytics. There are more potential side effects from tocolytics than fluids and
antibiotics. Tocolytics will also be less effective if the cause is infection
or dehydration
Scenario 3
Your Correc
orde t
r order Step Explanation
1 1 Educate Kesha about steroids and the need Patients should always be educated before being given a
to administer them. Verify that she new medication. They should have an understanding of
understands the rationale to receive the the medications side effects and reasons for giving it and
medication using the teach back method. express their understanding and consent prior to
administration.
3 2 Verify the 5 rights of medication The 5 rights should always be verified prior to giving a

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Your Correc
orde t
administration. medication.
2 3 Prepare steroids as ordered by the The medications should be given after education,
healthcare provider. consent, and 5 rights have been completed.
4 4 Choose large muscle for injection and offer Steroid injections should be given deep IM and may be
ice to site. painful, so ice should be offered.
5 5 Establish a plan with Kesha to receive the Steroids should be given in 2 doses, 24 hours apart. It is
second required dose of steroids in 24 important to establish a means for Kesha to get her
hours. If discharged, she may have trouble second dose. This is after the previous steps.
getting transportation and need assistance.
Scenario 4
Your Correct
order order Step Explanation
2 1 Use therapeutic Therapeutic communication should always be used when speaking
communication. with patients.
1 2 Allow her to express her It is important to allow her to express herself and explain what she
feelings and concerns. is experiencing.
4 3 Ask open ended questions to After the initial communication by the patient, attempt to develop
further develop the the conversation further by asking open ended questions and see if
conversation. she has more to communicate.
3 4 Answer any questions openly Answering questions and providing more information is important
and offer support. while you are in a teachable moment. Offer support for her and
encouragement as well.
5 5 Document the conversation. Documentation should be done last to include all elements of the
conversation.
Scenario 5

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Your Corre
orde ct
1 1 Use therapeutic communication Therapeutic communication should always be used when speaking
techniques. with patients.
2 2 Assess her cognitive level and It is important to assess the readiness and cognition level of a
readiness to learn. patient before beginning teaching so that the information can be
presented in the appropriate manner and at the appropriate time.
4 3 Discuss referral to social Information should be provided in a clear manner so that it is easily
work/case management. Provide understood. Written materials should be provided to allow them to
clear information along with have something to review later and to reiterate the teaching. She
printed material that she can is receptive to assistance, which may include transportation,
take with her. equipment, and finances, among other resources.
3 4 Allow her to ask any questions Questions should be allowed and answered after the teaching has
that she may have after teaching been provided so the patient can clarify anything they did not fully
is complete. understand.
5 5 Evaluate her understanding of After any teaching is completed, it is important to evaluate the
the information provided using patient’s understanding of the information provided.
proven techniques such as teach-
back or return demonstration.
Stephanie Gold Room 304
Stephanie Gold, 19-year-old Caucasian female, G1 T0 P0 A0 L0, 32 weeks gestation. Uncomplicated
pregnancy except for anemia treated with PO iron. States 3 times in last week has called on-call
obstetrician about fatigue, body aches, mild nausea during the evening. The client reports, “I don’t feel
well, I haven’t vomited, but nausea makes me not want to eat too much. I am drinking ok, just want to eat
bland foods.” Rest and acetaminophen were recommended. Client is first-year nursing student and states
several students have had a “GI bug”. States during day felt better and went to school all but one day. No

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fever. She stated: “Can’t be absent from nursing school!” No contractions, leaking of fluid or vaginal
bleeding. Came in this morning (Saturday) due to pain by right rib cage. States this is new today. Boyfriend
accompanies client.

Educational Needs Increased Status Assessment reports r/t change in condition
acuity
Fall Risk Increased Status Assessment reports r/t physiological shifts of pregnancy/center of gravity
acuity
Health Change Increased Status Assessment reports r/t malaise/nausea/pain during pregnancy
acuity
Pain Level Increased Status Assessment reports r/t right upper quadrant pain
acuity
Psychological Needs Increased Status Assessment reports r/t concern about her baby’s health/her health and absence from nursing school
acuity
Sensorium Normal acuity Status Assessment reports no indication in report that there is a change in sensorium
Physiological

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Your
Respons
Deficient Fluid False Status assessment reports no generalized edema from fluid shift from intravascular to
Volume extravascular at this assessment/nausea not significant enough to cause deficit.
Imbalanced False Status assessment reports assessments do not show nutrition has been substantially
Nutrition impacted by slight nausea.
Injury, risk for True Status assessment reports r/t risk for uteroplacental insufficiency secondary to
fetal vasospasm if abdominal pain and malaise/elevated BP indicate preeclampsia/HELLP
syndrome.
Injury, risk for True Status assessment reports r/t hypertension and vasospasm and potential decreased
maternal renal perfusion.
Nausea True Status assessment reports experiencing slight nausea off and on this week.
Safety
Your
Fall Risk True Status assessment reports r/t shifting center of gravity at 32 weeks gestation and
in the third trimester.
Injury, risk for True Status assessment reports r/t risk for worsening preeclampsia to eclampsia and
maternal seizures.
Love and Belonging
Your
Respons
Anxiety True Status assessment reports r/t unknown impact of current complication on mother
and fetus.
Disabled Family False Status assessment reports no evidence of inappropriate family coping. Boyfriend
Coping accompanies. Risk for r/t High Risk Pregnancy and Financial Concerns.
Health Maintenance; True Status assessment reports r/t deficient knowledge about high risk pregnancy.

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Your
Respons
Ineffective
1 Explain all plan of Explanation of plan of care

care to client and helps put client and
significant other. significant other at ease,
decrease anxiety. The must
be done first.
Bedrest/side-lying position. Left lateral recumbent position decreases pressure on vena
2 cava, therefore increasing venous return and placental and
renal perfusion. This ensures that the fetus is also well perfused
and is a priority.
CBC, Chemistry Panel, LFT, Contact the lab to come and draw these labs. The results of the
3 24-hour urine for protein lab will take several minutes and will drive the plan of care for
and creatinine. the client.
Continuous EFM. Client and healthcare team are concerned about fetus. Hearing
4 fetal heart will decrease client’s anxiety prior to taking her VS.
Verifies fetal wellbeing. EFM has been in place but ultrasound
and tocotransducer may need to be adjusted after turning
client onto her left side.
Hourly VS and DTR. Client’s BP was elevated and DTR were brisker than average.
5 By the time other actions have been taken, it will be close to
time for the hourly assessments.
Elevate Her DTRs are +3 so she is slightly

1and pad hyper-reflexic and at risk for
side seizures. Padding side rails
rails. protects her from injury if she has

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a seizure. Safety first!

2 Ensure oxygen and suction are Airway and breathing precautions next. If client has a seizure,
working properly. suction may be needed to clear airway. (She is already positioned on
her side) During a seizure, client would have a period of apnea which
would cause fetal hypoxemia. Applying oxygen to mother would
increase oxygen available to fetus. Ensure both are working before
needed in an emergency situation.
3 Emergency medications brought Magnesium sulfate, calcium gluconate, hydralazine, nifedipine are
to the client’s room or verified as often in an emergency “toolbox” and brought to client’s room for
accessible. immediate access if needed; anticipating one or more of these meds
will be ordered if complications such as preeclampsia, eclampsia, or
HELLP syndrome occur. This is done as per agency policy.
4 Bring extra pillows to enhance Enhancing comfort in the side-lying position will enable the client to
comfort in side-lying position and maintain this position. Side-lying decreases pressure on the vena
place between knees, behind cava, increases venous return, placental and renal perfusion.
back, and under abdomen. Comfort measures are completed after emergency interventions.
5 Bring bedpan, graduated cylinder, Healthcare provider ordered 24-hour urine so bringing supplies for
24-hour urine container, ice into this collection would be necessary. The nurse may include intake
the room. and output in the care plan independently. At least 30 mL of hourly
urine output demonstrates minimal kidney function. Left lateral
position enhances renal perfusion, thereby decreasing angiotensin
levels, and promotes diuresis. 24 hour I&O documents positive or
negative fluid balance.
6 Educate client and significant Educating and involving the client and significant others in the plan
others about 24-hour urine of care helps to decrease anxiety and empower them as important
collection, I&O and documenting members of
oral intake.
1 Educate the client Actively involving client in their

and her own care is a safety strategy,
significant other decreases anxiety, and gives the

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about the opportunity for verbal consent of

medication. the treatment.
Initiate peripheral IV with Magnesium sulfate is a high alert medication and should be
2 Lactated ringer’s infusing at 50 administered as a secondary medication. A primary line is
mL/hour. started with an isotonic solution, like Lactated Ringer’s. To
reduce the risk of pulmonary edema, total intake should be
less than 125 mL/hour.
Piggyback magnesium sulfate An initial loading dose of 4 to 6 grams over 15-30 minutes
3 solution into primary IV, set helps raise magnesium blood levels to a therapeutic level of
infusion at 400 mL/hour for 15 4-7 mEq/L and prevent eclamptic seizures.
minutes; volume to be infused
100 mL.
IM betamethasone 12 mg. While the loading dose of magnesium sulfate is infusing,
4 administer the IM steroid injection to enhance fetal lung
maturity for gestations less than 34 weeks. Neonatal benefit
is maximized when the interval between the first injection
and birth is longer than 48 hours, but benefits begin within 4
hours of administration. The benefit of one injection is
unclear but is often given without harm.
Change infusion rate to 50
5 mL/hour Magnesium sulfate 20
grams/500 mL for the remainder
of 400 mL.
Turn head to one Keep airway patent and

1 side and ensure provide for safety from
pillow under back head injury. Side rails
and shoulder is are up and padded.
snug.
Call for assistance but The nurse should call for help but do not leave the bedside. Informing
2 do not leave client. the family helps lower anxiety. Eclamptic seizures are frightening to

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Keep family informed of watch.

situation.
Administer oxygen via During the clonic phase of the seizure, the client will become apneic
3 non-rebreather mask at and may result in hypoxemia to the fetus. Respirations begin with
10 L/min. long, deep inhalation. Having the 100% O2 in place will provide for
additional oxygen to both mother and fetus.
Administer ordered 4 Since eclampsia occurred after initiating magnesium sulfate,
4 grams loading dose of additional magnesium sulfate should be given. It is the drug of choice
magnesium sulfate IV for treating eclamptic seizures and preventing repeated seizures.
in 15 minutes.
Observe and document Each stage of the convulsion should be timed and documented
5 convulsion activity. descriptively.
Administer IV Magnesium sulfate is the drug of choice over other antiseizure
6 lorazepam 2 mg over 3- medications because it does not depress the gag reflex. Lorazepam
5 minutes. or diazepam are only given if the client is receiving therapeutic levels
of magnesium and experiences repeated eclamptic seizures. THIS
OPTION IS NOT USED AS THE CLIENT IS HAVING HER FIRST SEIZURE.
1 Assess vital Assess post-seizure status of both

signs and client and fetus. Fetal distress may
FHR pattern occur from hypoxemia during the
post seizure. seizure. Monitor VS frequently
until stable.
2 Continue oxygen at 10 L/min per Next, administer oxygen to support oxygenation of the client
2 mask. and her fetus and resolve hypoxia.
3 Assess uterine activity and During the seizure the uterus may become hypercontractile and
3 abdominal focused assessment. hypertonic. Membranes may rupture, cervix may dilate rapidly.
The placenta may separate resulting in abruptio placenta. A rigid
broad-like abdomen, pain, and tenderness could be signs of this
condition.

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4 Assess for incontinence, provide The client may be incontinent during the convulsion. Provide
4 hygiene, insert indwelling urinary peri-care and insert and indwelling catheter with urinometer, for
catheter. hourly output. Urinary output decreases when there is a
reduction of glomerular filtration rate. Report output of < 30 mL/
hour.
5 Prepare to assist with the birth The cervix may dilate rapidly during a convulsion as the uterus is
5 process/instruct client and hypercontractile and hypertonic. Eclampsia alone is not an
significant other. indication for an immediate cesarean delivery- Route of birth is
determined by labor progression, maternal and fetal condition,
and gestational age. If abruptio placenta is confirmed with
ultrasound and cervix is not dilated, cesarean birth would occur.
Miranda Johnson Room 305
Miranda Johnson, 32 y/o G3P2 at 39 weeks gestation. It has been 10 years since her last pregnancy. She
was admitted to Labor & Delivery late last night in active labor. Upon admission, sterile vaginal exam
(SVE) was 2 cm dilated, 80% effaced and -1 station (2/80/-1). She had small amount of bloody discharge,
but membranes were intact. Contractions were every 3-4 mins., lasting 50-80 secs., with reassuring fetal
heart rate (FHR). She rated her pain as 3 on 0-10 pain scale and stated most of the pain was in her back
and vaginal area. Ms. Johnson was weighed on admission at 250 pounds, she reported that she is allergic
to penicillin, and has mild scoliosis. On admission, Ms. Johnson admitted that she does not tolerate pain
well and wants an epidural like she had with her previous pregnancies. Her significant other is in the room
on the couch playing games on his IPAD, and frequently texting on his phone. At 0630, her water broke
(SROM-spontaneous rupture of membranes) and fluid was clear. SVE is 4 cm dilated, 90% effaced, and 0
station (4/90/0) with contractions every 2-3 mins., lasting 40-70 secs., with reassuring FHR. Pain level is 7-
8 out of 10, and she became increasingly irritable, short tempered, and requested an epidural. IV fluids,
1000 ml of Lactated Ringers were infused at 125ml/hr. per order. There are signed orders for an epidural
PRN (as needed).

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Your
respons
Category e Explanation
Educational Increase Status report indicates patients last pregnancy was 10 years ago. Every pregnancy and labor are different therefore
Needs d acuity remedial labor and delivery education would beneficial. Patient also has mild scoliosis and weighs 250 pounds which could
increase the difficulty of epidural insertion. Proper positioning and breathing techniques during the epidural procedure
may lead to decreased difficulty of epidural insertion.
Fall Risk Increase Related to pregnancy and changes in balance and center of gravity.
d acuity
Health Increase Related to active labor and change in health status.
change d acuity
Pain level Increase Related to increased pain level of 7-8 out of 10.
d acuity
Physiologica Increase Related to active labor, increased pain, and desire for epidural.
l Needs d acuity
Sensorium Normal No indications
Needs acuity
Physiological
Your
Risk for Impaired Urinary Elimination False Related to fetal head position and bladder compression.
Risk for Maternal Injury True Related to epidural insertion and potential side effects

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Safety
Your
Deficient knowledge True Client has not had a child in 10 years and requires
education.
Fall, Risk for True Patient is term in pregnancy and has a change in center of
gravity.
Impaired maternal newborn bonding, False No indication.
Risk for
Risk for Ineffective Copin False No indication.
1 Review prenatal record It is the responsibility of each

with patient. Confirm nurse assigned to the patient to
pregnancy review the patients prenatal
complications, record. Allows for planning and
allergies, and orders for implementation of patient care.
epidural.
2 Witness signing of epidural It is the responsibility of the Anesthesiologist to assess
2 informed consent by the patient and to review and sign the Epidural
Anesthesiologist and patient consent. The nurses’ role is to witness the patient’s
AFTER preanesthetic evaluation. signature. Consents should be completed prior to any
protocol care related to the epidural catheter.
3 Initiate IV bolus per order in Helps to mitigate maternal hypotension that can result
3 preparation of epidural from a sympathetic blockade (epidural). Fluids should
procedure. be initiated prior to epidural insertion to pre-hydrate
client.
44 Gather epidural medications to Epidural analgesia can cause severe hypotension,
include Ephedrine, per therefore, Ephedrine, a vasopressor, should be readily

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Anesthesiologist orders, epidural available to correct hypotension. Hypotension reduces

tray, crash cart, nonrebreathing the blood supply to the fetus causing oxygen
mask, O2 tubing, and suctioning deprivation leading to a non-reassuring FHR.
equipment. Supplemental oxygen (100%) with a nonrebreathing
mask at 10L is recommended to correct oxygen
deprivation. o A severe reaction to epidural analgesia
is cardiorespiratory arrest. A crash cart and suctioning
equipment should be at the bedside during epidural
infusion.
5 Monitor patient BP, Pulse, O2 Vital signs should be assessed as follows: BP every 1-2
5 Sat, and FHR during epidural mins for 15 mins., after epidural bolus, then every 5-15
procedure according to mins until epidural blockade wears off. MHR and FHR
established guidelines. should be continuously monitored. o Epidural analgesia
can lead to sympathetic blockade, maternal
hypotension, transient uteroplacental insufficiency, and
alterations in the FHR.
1 Educate patient Epidural analgesia decreases

about the need for patients’ ability to determine the
a urinary catheter. need to urinate leading to urinary
Insert Foley retention. A full bladder will also
Catheter per impede fetal decent into the birth
protocol. canal.
22 Assess maternal and fetal Monitors maternal and fetal physiological response to
wellbeing using vital signs, fetal labor and epidural to include hypotension, oxygen
heart rate and other parameters. deprivation, and infection due to frequent vaginal exams
and epidural insertion. Monitors physiologic response to
active labor and epidural infusion.
3 Encourage repositioning every 30- Assists labor progression with fetal decent and deters
3 60 mins. Keep HOB elevated 30 unilateral epidural affects. HOB elevation of at most 30

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degrees and hip roll in place. degrees to prevent hypotension. Hip roll placement to
prevent aortocaval compression.
4 Reassess patients’ understanding PCEA (patient controlled epidural analgesia) is the button
4 of PCEA use. that the patient can push periodically according to the
pump setting entered by the Anesthesiologist. Strict
instructions should be given to both the patient and family
members that the patient is the ONLY person authorized
to push the button. This decreases potential overdosing.
Turn Stops infusion of epidural

1 epidural medication to resolve
pump off. hypotension.
2 Lower HOB, elevate foot of the Increases blood flow to the heart and head leading to increased
2 bed, and reposition patient to left maternal blood pressure. · Left lateral positioning provides uterine
lateral position. displacement thereby increasing blood flow to the fetus.
3 Rapid infusion (bolus) of IV fluids. Increases intravascular volume to prevent cardiorespiratory arrest.
3
4 Apply nonrebreathing oxygen Corrects fetal oxygen deprivation by promoting uteroplacental
4 mask and set to 10L/minute per perfusion.
order.
5 Consider administration of
5 Ephedrine.
1 Continually monitor Allows for continual assessment of

maternal vital signs maternal hypotension and
and fetal heart rate. nonreassuring FHR and possibility of
additional necessary interventions.

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2 Administer Ephedrine per protocol for Vasopressors are used for persistent hypotensive
2 hypotension. episodes following epidural medication
administration.
3 Notify the charge nurse and nursery Charge nurse will notify OR team and provide
3 personnel of STAT C-Section. additional nursing staff as needed. Nursery nurses
will notify Neonatologist and gather necessary
equipment for impending delivery.
4 Administer pre-op medications per Nausea and vomiting frequently occur in patients
4 anesthesia order. undergoing cesarean section which could lead to
aspiration.
55 Offer reassurance and emotional
support to both mother and significant
other.
Follow-up on Even though requests are made

1 requests made of of others, it is important to
other staff and follow-up care requests and
healthcare ensure emergent care and
providers. contact are made.
2 Maintain efficient, timely and Prevents possible documentation errors due to delay in
2 continual factual and accurate charting. o When care is provided and not documented in a
documentation. timely manner, failure to document the care can put a patient
at risk for getting a double dose of a medication(s),
unnecessary treatments, or a discontinuity in medical care. o
Prevents large gaps of time in the patient’s chart which can be
interpreted as a breach of duty in a lawsuit.
3 Discuss patient load with Communication is key to successful patient care. Patient
3 charge nurse. safety is priority and can be compromised with unrealistic
patient loads.
4 Always sign out when charting Others can chart on your patient under your name. The

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4 on a patient. medical record is a legal document and will be used against

you in a medical malpractice lawsuit. Your documentation is
your only defense. · NEVER let anyone chart under your name.
5 NEVER ASSUME your care or ALWAYS be able to support documentation with factual data
5 the care of others. and not assumptions.
Renee Workman Room 306
Renee Workman, Renee Workman, 35-year-old African American female, G2 T0 P0 A1 L0, 36 weeks
gestation, history of IVF with one failed implantation. Otherwise uncomplicated pregnancy. Reported
decreased fetal movement today. BP of 144/92 in office. Weight up 2 kg in 2 weeks since last appointment.
Urine +1 protein on dipstick. Mild headache and slightly blurry vision. No contractions, leaking of fluid or
vaginal bleeding. Wife accompanies client.

Educational Needs Increased acuity Status Assessment reports r/t potential diagnosis/preeclampsia.
Fall Risk Increased acuity Status Assessment reports r/t 36 weeks gestation/change in center of gravity.
Health Change Increased acuity Status Assessment reports r/t potential complication of pregnancy.
Pain Level Increase acuity Status Assessment reports r/t headache.
Psychological Needs Increased acuity Status Assessment reports r/t decreased fetal movement.
Sensorium Normal acuity Status Assessment reports r/t no evidence of changes in level of sensorium

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Saftey
Your
Fall Risk True Status assessment reports r/t shifting center of gravity at 36 weeks gestation.
Injury, risk for True Status assessment reports r/t risk for worsening preeclampsia to eclampsia and
maternal potential seizures.
Physiological
Your
Deficient Fluid True Status assessment reports r/t fluid shift from intravascular to extravascular spaces
Volume secondary to potential preeclampsia.
Imbalanced False Status assessment reports no evidence of this is status report, weight gain r/t
Nutrition generalized edema not nutrition.
Injury, risk for True Status assessment reports r/t uteroplacental insufficiency secondary to vasospasm
fetal from potential preeclampsia.
Injury, risk for True Status assessment reports r/t hypertension and vasospasm- decreased renal
maternal perfusion secondary to preeclampsia.
Nausea False Status assessment reports no evidence of nausea in the status report.
Love and Belonging
Your
Anxiety True Status assessment reports r/t unknown impact of preeclampsia on mother and fetus.
Disabled Family False Status assessment reports no evidence. Wife accompanies. Risk for r/t High Risk
Coping Pregnancy and Financial Concerns
Health True Status assessment reports r/t deficient knowledge about condition of potential
Maintenance preeclampsia and management
Scenario 1
1Wash hands/apply gloves. Prevention of spread of infection. Wash and don gloves prior to touching client for

lOMoARcPSD|7393617
assessment. Should be done on entering the room.

2Introduce self and explain Introduction and explanation of assessments help put client and spouse at ease,
assessments to be decreases anxiety.
completed.
3Apply electronic fetal Client is concerned about fetus due to decreased fetal movement. Hearing fetal heart
monitor. will decrease client’s anxiety prior to taking her VS. Verifies fetal wellbeing. Non-stress
test will take at least 20-30 to be done so apply EFM prior to taking maternal vital
signs.
4Assess maternal vital Client’s blood pressure was elevated at office. Need to fully assess by BP in both arms.
signs- temperature, pulse,
BP both arms.
5Auscultate heart and Generalized edema may cause increased workload on the heart and a murmur or
breath sounds. extra sound, S3 or S4, as well as crackles in the lungs
6Assess for peripheral Assessment progresses systematically in head to toe fashion so peripheral edema and
edema and reflexes. DTRs would be assessed last. Edema develops as fluid shifts from the intravascular to
extravascular spaces. Generalized edema of preeclampsia can cause significant pitting
edema in lower extremities related to gravity when the client has been ambulatory.
Generalized edema can also cause cerebral edema and irritability of CNS and
hyperreflexia. Baseline DTRs are important to assess of admission. Hyperreflexia may
occur as preeclampsia worsens
1Turn the client to her left Left lateral recumbent position decreases pressure on vena cava, therefore increasing
side and offer prescribed venous return and placental and renal perfusion. Acetaminophen to relieve headache.
acetaminophen.
2Elevate and pad side rails. Her DTRs are +3 so she has slightly hyperreflexia and is at risk for seizures. Padding
side rails protects her from injury if she has a seizure.
3Apply oxygen at 10 L/min Minimal fetal variability may be related to fetal hypoxemia so applying oxygen to the
per mask. mother increases perfusion to fetus. Reactive NST is reassuring so fetus may be in
sleep cycle but oxygen to mother won’t harm and might help.
4Emergency medications Magnesium sulfate, calcium gluconate, hydralazine, nifedipine are often in an
brought to the client’s emergency “toolbox” and brought to client’s room for immediate access if needed;
room/verify accessibility. have available before calling HCP, anticipating one or more of these meds will be

lOMoARcPSD|7393617
prescribed. Practice depends upon agency policy.

5Notify healthcare provider After doing all of these interventions to help the client and fetus quickly, notify the
of assessments. healthcare provider of the status change.
1Post signs and in the EHR/plan of Important to notify everyone involved in client’s care about 24-hour urine so
care regarding the 24-hour urine ALL urine is collected.
collection.
2Ask the client to void and discard The specimen collection begins with an empty bladder, so the first void is
the urine. discarded. The time is noted as the start of the 24 hours
3Place the urine in a special A special container is obtained from the lab, it either has preservatives or the
container or on ice. specimen needs to be kept on ice.
4Collect all urine in the next 24 Total volume of urine is part of the calculation of the results so every drop of
hours. urine must be saved. If there is a spill or flush of urine, the 24-hour period
starts over, and results are delayed.
5Ask the client to void and save At the 24-hour mark, the client is asked to void to empty her bladder (even if
the urine. she doesn’t feel the urge to void). The collection ends with an empty bladder.
6Label and send the urine All lab specimens must be correctly labeled and sent immediately to the lab
specimen to the lab. for results as soon as possible.
Renee Workman, blood work Situation

1 results reveal HELLP syndrome.
Renee is 36 weeks gestation, Background
2 came to clinic today d/t
decreased fetal movement.
NST reactive but minimal Assessments
3 variability. BP ranging 148-
160/96-100. +3 DTRs. HA
and blurry vision remain.
What magnesium sulfate Recommendation (SBAR)
4 loading dose and infusion

lOMoARcPSD|7393617
rate would you like to start

Renee on?
Read back HCP prescription: Repeat back verbal/phone prescriptions for
5 Magnesium Sulfate 4-gram accuracy.
loading dose in 15 minutes
followed by 2 gram/hour.
1 In a calm voice, remind the client Important the nurse remains
and her wife that this is an calm to then calm the client
expected side effect of the and wife. Flushing is an
magnesium sulfate related to expected side effect.
vasodilation.
Use therapeutic touch and Therapeutic touch demonstrates caring.
2 dim the lights in the room. Dimming the lights helps to decrease stimuli and
seizure risk.
Provide the client with a cool Applying the cool cloth and removing covers, yet
3 washcloth for her forehead; maintaining privacy, help to decrease
cover the client with sheet environmental temperature. These interventions
only and offer a fan. can be completed quickly before assessing vital
signs.
Assess the client’s vital signs Calming and cooling client prior to vital signs
4 and document FHR. assessment so vital signs are less impacted by
anxiety. Vital signs/FHR should be documented q
15 minutes during the magnesium infusion.
Ask the wife to leave the Presence of 1 or 2 support persons is often
5 client’s room. (not used) calming to the client. Asking her wife to leave
may increase the client’s anxiety.
Notify the healthcare Flushing is an expected side effect not an
6 provider of the adverse adverse reaction. The healthcare provider does
effects of the medication. not need to be notified at this time.
(not used)
Clara Guidry Room 301

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Clara Guidry, Mrs. Clara Guidry 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.
Educational Increased Status assessment reports uterine atony and bleeding and need for fundal massage.
Needs acuity
Fall Risk Increased Status assessment reports patient is still numb from epidural and unable to move legs.
acuity

lOMoARcPSD|7393617
Health Change Increased Status assessment reports pooling of blood with large clots.
acuity
Pain Level Normal Status assessment does not indicate report of pain and patient is still under effects of epidural anesthesia.
acuity
Psychological Increased Status assessment reports pooling of blood, patient reports feeling light-headed, appears pale, indwelling urinary
Needs acuity catheter removed and patient unable to sense need to void.
Sensorium Increased
Status assessment reports patient reporting feeling light-headed and still numb from epidural and is feeling anxious.
acuity
Physiological
Your
Respons
Acute Pain False Status assessment reports lingering numbness from epidural.
Bleeding True Status assessment reports blood pooling under buttocks with large clots,
most likely secondary to uterine atony because of multipara status, rapid
second stage, oxytocin use and large infant.
Deficient fluid volume related True Status assessment reports blood pooling under buttocks with large clots.
to uterine atony/postpartum
hemorrhage
Impaired mobility True Status assessment reports effects continued numbness from epidural.
Impaired patterns of False Status assessment reports continued numbness from epidural with
elimination urinary catheter having been removed previously; patient unable to
sense a full bladder which can contribute to uterine atony and
hemorrhage.
Ineffective tissue perfusion True Status assessment reports blood pooling under buttocks and large clots,
related to hypovolemia feeling anxious and light-headed and appears pale
Infection False Status assessment reports no indication of a current infection.
Nausea False Status assessment reports no indication of increased risk.
Safety

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Your
Respons
Deficient knowledge True Status assessment reports patient reports feeling wet and may have urinated on
self and still numb from epidural; unaware of potential for uterine atony and
hemorrhage, client and husband both require education and support.
Disturbed sensory True Status assessment reports patient is still numb from epidural.
perception
Fall, risk for self and True Status assessment reports lingering numbness from epidural and unable to move
risk for dropping legs; reports feeling light-headed
baby
Impaired maternal False Status Assessment reports mother is currently holding and breastfeeding baby.
newborn bonding
Peripheral False Status assessment reports no indication of increased risk.
Neurovascular
Dysfunction
Scenario 1
1Assist mother to unlatch infant from Patient is light-headed and hypovolemic putting infant at risk of falling
1 breast and place infant in crib or hand from mother’s arms. Infant safety is a first priority.
to the husband.
2Massage uterine fundus. Massaging the fundus until firm and tightly contracted closes off blood
2 vessels at the placental site and stops bleeding. This can be done
quickly prior to calling for help.
3Call for help using emergency call Postpartum hemorrhage is the leading cause of morbidity and mortality
3 system. requiring a rapid, team approach to patient management.
4Set oxytocin rate to Bolus on IV pump Rapid infusion of oxytocin causes a sustained contracted uterus,
4 as ordered by healthcare provider. thereby clamping off blood vessels from placental site and preventing
hemorrhage.
5Assess bladder status and need to A full bladder displaces the uterus and contributes to hypotonia and
5 perform straight catheter. uterine atony. Her uterus is slightly deviated to the right, indicating a

lOMoARcPSD|7393617
potential need for catheterization.
Scenario 2
1 1Educate patient regarding indwelling Education allows for planning and implementation of patient care;
urinary catheter placement, Wash washing hands prior to indwelling urinary catheter placement prevents
hands. nosocomial infection during invasive procedure and is the first step.
2Insert indwelling urinary catheter and Insertion of Indwelling urinary catheter is done according to
2 connect to collection bag, secure to established protocols, under sterile technique and is the second step.
patient’s thigh. The patient is unable to void, and a full bladder is a common cause of
uterine atony and early postpartum hemorrhage.
3Measure urine return in collection bag; Assesses adequate emptying of bladder; emptying bladder returns
3 Reassess uterine tone, response to uterus to normal and position and facilitates normal contraction of the
massage, level in relation to umbilicus, uterus.
and position in abdomen.
4Reassess vaginal bleeding and presence A firmly contracted uterus clamps off blood vessels at the placental
4 for clots; change underpads as needed. site, preventing uterine atony and excessive bleeding, changing
underpads for patient comfort and prevention of infection.
5Wash hands, document findings and Prevents spread of infection; accurate documentation is to be
5 completion of procedure. performed after patient care is performed, NEVER BEFORE!
Scenario 3
1 Reassess Indicates physiologic response to fluid
vital resuscitation and uterotonic meds, BP must be
signs. assessed prior methergine administration.
2 Set plain Lactated Ringers to Bolus rate on IV Next the nurse must address fluid resuscitation to
2 pump. treat hypovolemia and fluid loss.
3 Administer Methergine 0.2 mg IM per Methergine causes a sustained firm contraction of the
3 healthcare provider order. uterus, clamping off blood vessels at the placental
site, decreasing excessive bleeding.

lOMoARcPSD|7393617
4 Assist healthcare provider with exam to assess Unrecognized cervical/vaginal lacerations from a rapid
4 for cervical or vaginal lacerations/hematoma or second stage labor and large fetus can be the cause of
retained placental pieces. excessive vaginal bleeding, especially with a firm
fundus.
5 Anticipate laboratory studies: CBC, blood typing Laboratory studies reveal degree of hemorrhage,
5 and crossmatch, coagulation studies. coagulopathies which can cause hemorrhage and aid
in patient management.
Scenario 4
1 Administer Oxygen Hypovolemia from blood loss and
via nonrebreather decreased perfusion decreases
face mask at 10-12L/ circulating oxygen levels to brain and
min. other vital organs. Oxygen is a
priority.
2 Assist healthcare provider with Causes a sustained firm contraction of the uterus,
2 administration of misoprostol clamping off blood vessels at the placental site,
(Cytotec) 1000 mcg rectally. decreasing excessive bleeding. This medication
may be given quickly via rectum while obtaining
other IV line.
3 Establish an additional IV line and Fluid resuscitation and blood administration is
3 anticipate additional crystalloids critical to restoring blood volume and successful
(Lactated Ringer’s), colloids management of woman with postpartum
(albumin), blood and blood products. hemorrhage.
4 Continue to closely monitor vital Indicates physiologic response to fluid and blood
4 signs, uterine fundus tone/level and resuscitation, uterotonic meds and postpartum
vaginal bleeding. balloon with rapid installation components.
5 Anticipate healthcare provider Balloon exerts inward to outward pressure against
5 insertion of postpartum balloon and/or the uterine wall, resulting in a reduction in
return to operating room. persistent capillary and venous bleeding from the
endometrium and myometrium.
Scenario 5

lOMoARcPSD|7393617
1 Use therapeutic communication/active Active listening allows patient to express

listening to assess patient’s concerns and herself concerning choices of infant feeding
interest in pumping for colostrum. and should be done first.
2 Consult Lactation Consultant or provide Provides expert
2 education to patient and assist with assistance in learning
pumping. new skill.
3 Discuss with patient’s partner for Allows choices in infant
3 willingness/interest to feed baby colostrum. feeding and promotes
paternal-infant bonding.
4 Assist partner in feeding pumped colostrum Promotes confidence in
4 and partner skin-to-skin contact. learning a new skill.
5 Assess patient’s ability to hold infant and Facilitates maternal-
5 assist patient with holding baby skin-to-skin infant bonding and
after feeding for maternal-infant bonding. confidence in maternal
role.
Cindy Mason Room 302
Cindy Mason, 28 y/o G2P1 at 40 weeks gestation. She and her husband present to OB Triage with
complaint of early labor. Her prenatal history indicates an uncomplicated first pregnancy with a
spontaneous vaginal delivery. Her current pregnancy has also been uncomplicated with no risk factors
identified. She and her husband have attended Lamaze Prepared Childbirth classes and their Birth Plan
indicates a desire for an unmedicated labor and birth and breastfeeding. Mrs. Mason states her
contractions are occurring every 4 minutes and lasting 60 seconds. She is using slow-chest breathing and
rates her pain at 4/10. She also reports leaking clear fluid from her vagina. She believes the leaking began
about two hours ago.

lOMoARcPSD|7393617
Your
Educational Increased Status assessment reports attendance at Lamaze classes and previous vaginal delivery, but may benefit from
Needs acuity additional coaching for labor management
Fall Risk Increased Client is at full term of pregnancy and has a changed center of gravity.
acuity
Health Change Increased Status assessment reports active labor with possible spontaneous rupture of membranes.
acuity
Pain Level Increased Status assessment reports frequent contractions with pain score 4/10.
acuity
Psychological Increased Status assessment reports active labor with desire for unmedicated labor and birth.
Needs acuity
Sensorium Normal Status assessment reports no indication of increased sensorium acuity or changes in level of orientation.
acuity
Physiological
Your
Fatigue Related to Energy Expenditure True Status assessment reports frequent contractions requiring la
Required for Labor and Coping Skills techniques
Impaired Comfort True Status assessment reports frequent contractions, use of brea
and report of pain 4/10

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Your
Infection, Risk True Status assessment reports potential for spontaneous rupture
increasing risk for infection for mother and fetus.
Nausea False Status assessment does not indicate increased risk for nause
Risk for Fluid Volume Deficit False Status assessment does not indicate increased risk for fluid v
Risk for Impaired Urinary Elimination True Status assessment indicates active labor which can impede
bladder
Safety
Your
Deficient knowledge True Status report indicates attendance at childbirth classes but each labor is differen
variety of coping skills
Disturbed sensory False Status assessment indicates no disturbance in sensory perception
perception
Scenario 1
Correct
order Step Explanation
1 Review prenatal history with patient and Allows for planning and implementation of patient care,
Birth Plan. ensures measures implemented are within Birth Plan and
agency policy and should be done first.
2 Obtain maternal vital signs. According to stage and phase of labor. Establishes baseline
and on-going tolerance to labor process.
3 Perform Leopold’s Maneuver. Identify position of fetus and location of fetal back to apply
fetal and contraction monitoring.
4 Apply fetal transducer and external Detects and records uterine contractions; assesses contraction
tocodynamometer and palpate fundus intensity. Detects and records FHR which is best heard through
during contractions. fetal back.

lOMoARcPSD|7393617
Correct
5 Perform a Sterile Vaginal Exam. Assesses dilation, effacement, station and status of fetal
membranes.
Scenario 2
Correct
1 Assess fetal status and contraction pattern The fetus is the first priority. Monitors physiologic response to
according to stage and phase of labor. labor and birth as well as labor progress.
2 Reassess maternal vital signs, including The nurse should then monitor the mother’s physiological
temperature; assess temperature every response to labor; risk for infection with spontaneous rupture
two hours. of membranes.
3 Assess color and character of amniotic Amniotic fluid should be clear with no foul odor; meconium
fluid. stained fluid indicative of potential alterations in fetal
response to labor.
4 Encourage ice chips and clear liquids such Facilitates hydration and nourishment.
as apple juice, popsicles.
5 Encourage frequent position changes and Comfort and relaxation measures; facilitates progress in
hydrotherapy in shower labor.
Scenario 3
Correct
1 Praise her efforts and tell her that she is Decrease anxiety and encourage on-going use of
almost ready to deliver techniques. Decreasing anxiety can facilitate labor and
should be the initial nursing action.
2 Encourage her to void at least every two Avoid bladder distention which can impede fetal descent;
hours promote comfort.
3 Assist her with peri-care and change Provides comfort and prevents infection

lOMoARcPSD|7393617
Correct
underpads as needed
4 Teach husband how to apply counter- Relieves back pain that may be associated with fetal
pressure to woman’s back during posterior position; encourages pelvic mobility and perineal
contractions while sitting on birthing ball. relaxation to encourage fetal descent
5 Continue to provide comfort measures and Decrease discomfort and aid in focus on non-pharmacologic
minimize distractions in room labor techniques
Scenario 4
Your Correc
order t order Step Explanation
1 Assist woman to birthing bed and place Side-lying decreases pressure on perineum and allows for
in lithotomy or side-lying position for gradual stretching; optimal for utero-placental perfusion.
birth. Focus on the client first.
2 Request assistance for room set up and The room must be set up and ready with appropriate
for delivery. equipment and personnel for a safe delivery.
3 Ensure neonatal resuscitation equipment Always anticipate neonatal resuscitation despite
readily available. reassuring assessments during labor reduces risk for
perinatal trauma.
4 Encourage woman to push Less fatigue and enhanced comfort; decreases risk for
spontaneously when she feels the urge perineal trauma, less risk for fetal hypoxia secondary to
to do so rather than directed pushing maternal Valsalva maneuver with directed pushing
5 Encourage deep breaths and relaxation Conserves energy, maintains adequate oxygen levels for
in-between each contraction mother and fetus, thereby maintaining fetal well-being
Scenario 5

lOMoARcPSD|7393617
Your Correct
1 Perform an Apgar Score on Rapid assessment of newborn’s transition to extrauterine life
infant at 1 and 5 minutes of based on five signs that indicate newborn’s physiologic state.
birth.
2 Place the infant in skin to skin Prevents evaporative heat loss; provides neonatal temperature
contact with mother. stabilization; promotes maternal-infant bonding and stimulates
early lactation behaviors.
3 Reassess maternal vital signs. Monitors physiologic response to birth and immediate postpartum
adaptation
4 Reassess uterine fundus for A firmly contracted uterus clamps off blood vessels at the
tone and location, if boggy placental site, preventing uterine atony and excessive bleeding.
massage till firm.
5 Reassess lochia for amount and Post-birth uterine discharge is initially similar to a heavy
color; note any clots or odor. menstrual period; flow steadily decreases and should be free of
clots
Maria Sanchez Room 303
Maria Sanchez, 20-year-old female, G1 T1 P1 A0 L1, 39 weeks gestation. Pregnancy uncomplicated. O+,
Rubella immune, GBS 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 degrees C; AP 156 beats/minute,
regular; R 52 breaths/minute, irregular. Skin-to-skin with mother for first hour. Beginning to show hunger

lOMoARcPSD|7393617
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.

Educational Needs Increased acuity Status Assessment reports r/t first postpartum and newborn experience
Fall Risk Increased acuity Status Assessment reports r/t 1 hour postpartum; legs “tingly” from epidural in labor
Health Change Increased acuity Status Assessment reports r/t 1 hour postpartum- first baby
Pain Level Increased acuity Status Assessment reports r/t perineal discomfort; 1st degree laceration
Psychological Needs Increased acuity Status Assessment reports r/t new experiences of postpartum
Sensorium Normal acuity Status Assessment reports Alert and oriented but tired
Saftey
Description Your Response Explanation

Fall Risk True Status assessment reports r/t paresthesia in lower extremities.
Injury, risk for maternal False No indication
Physiological

lOMoARcPSD|7393617
Your
Acute Pain True Status assessment reports r/t perineal laceration.
Chronic Pain False Status assessment reports no history of chronic pain.
Ineffective True Status assessment reports r/t risk decreased milk supply; “las dos cosas”
breastfeeding, risk for (both breast and bottle feeding).
Infection, risk for True Status assessment reports r/t perineal laceration.
Love and Belonging
Your
Deficient Knowledge True Status assessment reports First experience with postpartum, newborn,
and breastfeeding.
Readiness for Enhanced True Status assessment reports Husband present; female family members
Parenting present and supportive.
------------------------------------------------------
scenario 1
1.)Wash hands and introduce self to the client and her husband.
2.) Ask client and her husband what they prefer to be called.
3.) Ask Maria if she agrees with her mother; if so, bring a bottle to the room for feeding the newborn.
4.) Ask permission prior to touching the client. Obtain her vital signs, perform a pain assessment and assessment of
fundus, lochia, and perineum.
5.) Assess newborn vital signs and head-to-toe assessment.
-----------------------------
Scenario 2
1.)Reassure Maria that engorgement is a common and temporary condition; lasts about 24 hours, caused by the milk
coming in as well as increased blood supply and swelling.
2.)Instruct Maria to breastfeed Juan every 2-3 hours; 15-20 minutes/breast; 8-12 times in 24 hours
3.)Provide a breast pump and instruct Maria to use it after breastfeeding to soften the second breast if needed.
4.)Apply cold packs between feedings to relieve swelling; 15-20 minutes on and 45 minutes off.

lOMoARcPSD|7393617
5.)Ibuprofen 600 mg orally can be taken every 6 hours.

-----------------------------
scenario 3
1.) Position your baby skin-to-skin with you for a few minutes."
2.) "Hold your baby like a football."
3.) "Roll your nipple between your thumb and index finger so it stands out. Express a drop or two of milk."
4.) "Support the breast with thumb on top and 4 fingers underneath the breast."
5.) "Tickle your baby's bottom lip with the nipple. Watch for him to open wide, then quickly bring him to the breast."
-------------------------
Scenario 4
1.)"Juan should have 6-8 wet diapers of light-yellow urine every 24 hours. It's a good idea to write them down to help you
remember."
2.)"By the 4th day, Juan should have at least 3 yellow-green stools and they should be looser than the dark green stools
he had on the first few days."
3.)"Juan latches easily, has bursts of suck/swallows, you hear him swallow, easily releases the breast after 15-20
minutes, and appears content at the end of the feeding."
4.)"You feel Juan tug at the breast but no pain, you have some uterine contractions and maybe a little bit of vaginal
bleeding during the feeding, you are thirsty and feel relaxed, and your breasts feel lighter or softer at the end of the
feeding."
5.) "You can bring Juan into the clinic for Baby Weigh-In and have his weight checked. You can also talk to the lactation
consultant. She can even observe a feeding to help you."
--------------------------
Scenario 5
1.)"Maria, take 3 deep breaths in and exhale slowly while I count to 3."
2.)"An appointment can be made for first thing in the morning so you do not have to wait in the waiting room at the
lactation clinic. The lactation nurse is an expert and will be able to help you."
3.)"You are a good mother, Maria. You are doing an excellent job of keeping the feeding diary and trying many options to
help your baby. Bring your feeding diary with you to your appointment."
4.)"Spend time with Juan skin-to-skin before attempting to latch-on for feeding. Undress Juan down to his diaper to help
him wake up for the second breast. Express milk using the pump if he doesn't feed 20 minutes on each side."
5.)"Sleep when Juan sleeps. Tell your mother and grandmother they can help you best by fixing meals and doing
household chores so you can rest."

lOMoARcPSD|7393617
Jessica Wu Room 304
Jessica Wu, 35-year-old Asian female, G3 T2 P2 A0 L2, 35 weeks gestation. NKDA. Previous pregnancies
uncomplicated but Cesarean births d/t 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
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.

Educational Needs Increased Status assessment reports r/t change in condition and bleeding
acuity
Fall Risk Increased Status assessment reports r/t 35 weeks gestation (third trimester and changed center of gravity)
acuity
Health Change Increased Status assessment reports r/t complication of pregnancy and bleeding.
acuity
Pain Level Decreased Status assessment reports No pain or contractions noted in the report.
acuity
Psychological Increased Status assessment reports r/t concern about condition and stress related to the unknown outcome of this

lOMoARcPSD|7393617

Needs acuity new change
Sensorium Normal acuity Status assessment reports alert and oriented X4. Drove herself to hospital.
Ms. Susie Smith Room 305

Ms. Susie Smith, 33 y/o G2P0 at 42 weeks’ gestation. She is single with a limited support system. She has
just completed a Non-Stress Test (NST) which was interpreted as being Non-Reactive. Her obstetrician has
now ordered an Oxytocin-Stimulated Contraction Stress Test (CST). Fetal membranes are intact. Ms. Smith
also has a history of hypertension and a previous pregnancy loss at 18 weeks’ gestation. She is crying and
states “I can’t lose another baby”. External tocodynamometer and fetal ultrasound transducer remain in
place from the NST.

Educational Needs Increased acuity Status assessment reports order for additional testing procedure.
Fall Risk Increased acuity Related to late stage of pregnancy and change of center of gravity.
Health change Increased acuity Status assessment reports post-term pregnancy with non-reactive NST.
Pain level Normal acuity Status assessment does not indicate report of pain.
Physiological Needs Increased acuity Status assessment reports need for additional maternal-fetal testing.
Sensorium Needs Normal acuity Status assessment reports no indication of altered sensorium.

lOMoARcPSD|7393617
Physiological
Your
Respons
Acute Pain False Status assessment reports no indication of pain.
Anxiety True Status assessment reports patient crying and expressing fear of losing a second
pregnancy.
Bleeding False Status assessment reports no indication of bleeding.
Infection, Risk False Status assessment indicates intact membranes and no increased risk for
infection.
Nausea False Status assessment reports no indication of nausea.
Risk for Impaired Fetal True Status assessment indicates post-term pregnancy at 42 weeks gestation.
Gas Exchange Placental reserve can be decreased affecting its ability to oxygenate fetus.
Safety
Your
Deficient Knowledge True Status assessment reports additional testing required, requires additional
education.
Disturbed sensory False Status assessment reports normal sensory perception.
perception
Fall, Risk for True Status assessment reports mother is post-term, changes in center of gravity
and balance may increase risk for fall.
Impaired Maternal Infant False Status assessment reports no indication of increased risk.
Bonding, Risk for
Maternal Injury, Risk for True Status assessment reports planned use of oxytocin, a high-alert medication
requiring careful titration to prevent uterine tachysystole.
Risk for Ineffective Coping True Risk assessment reports minimal family support; patient visibly upset.

lOMoARcPSD|7393617
Scenario 1
1 Discuss with woman fears Therapeutic communication
about baby health; offer establishes a trusting nurse-patient
reassurance. relationship.
2 Educate woman on oxytocin Education allows for planning and
2 contraction stress test (CST) implementation of patient care, allays anxiety
procedure. and reduces stress.
3 Have woman empty her bladder. Provides patient comfort during procedure.
3
4 Position woman in Semi-Fowlers Optimizes utero-placental perfusion by
4 position with left lateral tilt. preventing supine hypotension secondary to
vena cava compression.
5 Reassess placement of Ensures accurate detection and recording of
5 tocodynamoneter and transducer. uterine contractions or fetal movements.
Scenario 2
Your Correc
1 1 Assess maternal vital signs. Establish baseline immediately prior to
initiation of oxytocin.
2 2 Assess FHR baseline and reactivity. Establish baseline fetal status
immediately prior to initiation of
oxytocin.
3 3 Assess monitor tracing for presence of contractions, Abnormal contraction patterns, including
palpate uterine fundus for contractions. uterine tachysystole can occur with use
of oxytocin.
4 4 Obtain IV access with #18 gauge IV catheter and begin Mainline fluid infusion ensures
1000 ml Lactated Ringer’s solution at 125 ml/hour on IV continuous venous access if oxytocin
pump. needs to be discontinued and adequate
hydration.
5 5 Administer oxytocin intravenously through a secondary Prevents an inadvertent bolus of

lOMoARcPSD|7393617
Your Correc
line connected to the main line at the proximal port with oxytocin if discontinued and mainline LR
an IV pump; begin at 1 mu/min per healthcare provider is increased.
prescription.
Scenario 3
Assess contraction Validate contraction pattern per
1 pattern and palpate monitor tracing and determine if there
uterine resting tone. is an indication to adjust oxytocin rate.
2 Assess fetal status. Fetal status must be reassuring to increase
2 oxytocin rate.
3 Reassess maternal vital signs. Alteration in maternal vital signs can occur with
3 increasing oxytocin dosages.
4 Increase oxytocin to 2 mu/minute per Assessment indicates continued upward titration
4 healthcare provider order. of oxytocin dosage per contraction stress test
protocol and healthcare provider orders.
5 Educate and reassure the client. Education allows for planning and
5 implementation of patient care.
Scenario 4
Your Correct
1 1 Palpate fundus for resting tone To determine response to oxytocin and verify intensity of
and contraction intensity. contractions.
2 2 Collaborate with healthcare Collaboration with healthcare provider regarding accurate
provider on CST interpretation. interpretation of CST results; No late decelerations of FHR indicate
negative test.
3 3 Discontinue oxytocin infusion. Negative CST has been achieved with verification of results with
healthcare provider.

lOMoARcPSD|7393617
Your Correct
4 4 Educate client on test results.Negative CST indicative of positive fetal outcome; woman may be
confused with terminology.
5 5 Document assessment and test Accurate documentation is done after performance of patient care.
results.
Scenario 5
1 Using a sterile gloved Nitrazine paper differentiates
hand, test fluid leaking amniotic fluid (alkaline) from
from vagina with Nitrazine urine (acidic).
paper.
2 Reapply tocodynamometer and Continued maternal/fetal assessment with
2 transducer to maternal spontaneous rupture of membranes and labor
abdomen. initiation is needed due to new onset spontaneous
rupture of membranes.
3 Maintain IV access with Lactated To facilitate medication administration and labor
3 ringer’s infusion. management.
4 Notify healthcare provider of Healthcare provider and nurse interpret assessment
4 assessment findings and data and new findings to change plan of care and
collaborate on plan of care. planned discharge.
5 Reassure woman and educate Client will require teaching and support due to
5 on plan of care. initiation of labor and change in plan of care.
Jenny Smith Room 306
Jenny Smith, 23-year-old, G2P1, estimated gestation age of 10 weeks with complaints of vaginal bleeding
and abdominal cramping. No medical hx, allergic to sulfa drugs. Lab results showed a decreased serum
HCG from previous result. No fetal movement seen by ultrasound and no fetal heart tones could be

lOMoARcPSD|7393617
obtained. Pelvic exam revealed an open cervical os with blood noted. She states that her pain is abdominal
cramping, rates it from a 4/10 to a 7/10 and is still having vaginal bleeding. She has pain medication
prescribed q4h prn and received a dose about 1 hour ago with some relief. Her vitals are stable at 98.1o
F., Heart rate 89 bpm, 18 breaths/minute, 132/68 mmHg, O2 Saturation 98% on room air. She’s currently
NPO until the need for dilation and curettage is ruled out. She has an IV in her left forearm, no fluids
infusing at this time. She verbalized understanding of the findings and is visibly upset. She expresses
concern about her family dealing with the loss and how she will tell them. She has been speaking with the
staff about loss and is receptive to education regarding the next steps.

Educational Needs Increased acuity Jenny will need education regarding dealing with the loss both mentally and physically.
Fall Risk Increased acuity She may be at increased fall risk related to bleeding, pain, and pain medication.
Health change Increased acuity She needs to be monitored for hemorrhage from the vaginal bleeding.
Pain level Increased acuity The client rates their pain at 7/10.
Physiological Needs Increased acuity Client is grieving a loss and expresses concern about herself and others coping.
Sensorium Needs Normal acuity No issues reported here.
Physiological
Your
Acute Pain True Client rates pain 7/10 pain.

lOMoARcPSD|7393617
Your
Altered family processes True Roles have been changed due to the loss.
Anxiety True Client is expressing anxiety over loss.
Bleeding True Client is still having vaginal bleeding.
Decreased cardiac output False Vitals are stable, no signs of cardiac compromise.
Depression, risk for True Client has not relayed any feelings of depression.
Grieving True Client is currently grieving a loss.
Ineffective airway clearance False There are no reports of airway compromise.
Ineffective coping False Client seems to be coping so far, expresses feelings and responding.
Infection, risk for True Client is at risk for infection is miscarriage is incomplete.
Nausea False Client no reports of nausea.
Suicidal ideations False Client has not expressed thoughts of suicide.
Safety
Your
Fall, risk True Client may be a fall risk due to pain medication, pain, and bleeding.
Impaired False Client is able to express feelings at this time with staff.
communication
Impaired mobility False Client has no mobility issues have been identified.
Knowledge deficit True Expresses uncertainty about how to explain loss to others, resources should
also be provided.
Use therapeutic Therapeutic communication should always be

1 communication and used. The nurse should offer to listen in case she
express that you are does feel like talking. She might open up if given
here to listen if she time. Statements could include “It sounds like
wishes to talk. you were looking forward to growing your family.
I wish the ultrasound had shown better news.”

lOMoARcPSD|7393617
2 Assess her overall condition and vital signs if Assess the condition of patient to
2 available. ensure that she is stable to be left alone
at this time.
3 Respect her wish to be alone at this time and ask It is normal in the grieving process to
3 if there is anyone to call/reassure you will return. not wish to speak to others for a time.
She is stable and has not opened up so
should be left alone. A call to a
friend/family member may assist.
Important to return to support the
client.
4 Ensure that call light in reach and leave the Always make sure the patient has
4 room. access to call for help and is safe before
leaving.
5 Document the conversation. Documentation should be completed for
5 the physician and other staff to see and
should be done last to include all the
information needed.
1 1Assess vital signs. Assessing vital signs will ensure the patient is stable and that its
ok to give pain meds. If vitals are abnormal it could indicate
complications.
2Assess amount of current vaginal bleeding. ncreased pain could be caused by active miscarrying so
2 bleeding should be assessed first. Immediate action will need to
be taken if she is bleeding excessively.
3Administer pain medication as prescribed She has prn pain medication that she has been needing and
3 using to relieve discomfort.
4Educate about spontaneous miscarriage and Always educate patients about the medications they have
4 about medication action and effects and received and what they can expect after taking them.
evaluate understanding.
5Document event in the chart. It is important to document all that you’ve done for other
5 providers to reference.

lOMoARcPSD|7393617

1 1Assess vital signs. An elevated temp, high heart rate, and/or low bp could be signs of complications and
will need to be reported to provider.
2Assess vaginal bleeding Increased bleeding could indicate an incomplete miscarriage. This needs to be
2 amount and odor. addressed quickly.
3Estimate and compare It is important to have some point of reference to determine how significant the
3 previous and current changes are in bleeding amounts.
blood loss.
4Notify the healthcare The healthcare provider needs to be given a detailed description of the patient’s
4 provider. status so data should be gathered prior to calling. The nurse should anticipate the
need to administer IV fluids and to check hemoglobin.
5Document findings and Documentation should be done last to include all the information.
5 notification of healthcare
provider.
Explain to The client needs to be educated

1 Jenny about on the plan of care.
the plan of
care.
2 Ensure that the consent is Obtaining the patient’s consent should always be done first. If
2 obtained prior to the surgery. they refuse the surgery or have questions for the provider then
you would not proceed with other interventions.
3 Assess NPO status to ensure If the patient has not been NPO long enough, the surgery may be
3 that she has been NPO for the pushed back to allow sufficient time to pass. If it is determined
proper period of time. that she needs to go regardless of NPO status, anesthesia will
need to be made aware of her last food and drink.
4 Administer pre-op medications Pre-operative medications are generally given within 1 hour of
4 as indicated. surgery.
5 Give report to the operating OR staff receiving the patient needs to be given a full report prior
5 room staff and ensure support is to assuming her care including NPO status, the surgical consent,

lOMoARcPSD|7393617
given to the client related to and pre-op medications. Support should be provided in a caring
perinatal loss. and sensitive manner due to perinatal loss.
1 Assess Vital signs should be checked

Jenny’s quickly and regularly post-op to
current allow for baseline set for you and
vital signs. to note any subtle changes that
may indicate a problem.
2 Assess current bleeding. Bleeding needs to be checked regularly as an increase can
2 indicate a complication.
3 Assess current urinary output. Urine output would indicate hydration status and significance of
3 estimated blood loss and cardiovascular stability. Client should
void prior to discharge.
4 Speak with Jenny and inform her Jenny should be updated about her status and be made
4 that she is back in her room and comfortable. Pain is an important assessment but is normal after
that she is doing well. Assess her surgery so can be checked after the other things which could
current pain level. indicate issues.
5 Inform Jenny that her family is The client has the choice to see family members and who she
5 waiting and offer to bring them in wants to see. She may not have disclosed the pregnancy or may
to be with her. not want to see all family members. Family members may be
updated as soon as possible but only after you have assessed the
patient and determined that they are stable.
Assess Jenny’s Vital signs, bleeding, pain,

1 current and ability to void should
status/physical be assessed for stability
readiness for prior to discharge.
discharge.
2 Verify blood type. If she is Rh- she would need Rh immune globulin prior to
2 discharge.
3 Education about follow-up She should see her provider in 1-2 weeks to ensure safe physical

lOMoARcPSD|7393617
3 with provider. recovery, and to discuss either birth control or planning next
pregnancy if she expresses desire to try again.
4 Educate about warning She should know when to call provider- for fever, increasing pain,
4 signs of complications. or excessive bleeding, and be able to “teach back” explain
warning signs in her own words.
5 Offer support for Let her know that grief after a pregnancy loss may take time,
5 pregnancy loss. that there may be some days she is especially sad, like her due
date (when she expected to be having a baby), that she and her
partner may not grieve the same way, to reach out for support
from friends, or other sources as needed (counselor, support
group, on line resources).
Aminiah Hussain
Educational Needs Increased acuity Status assessment reports r/t first pregnancy and induction of labor.
Fall Risk Increased acuity Status assessment reports r/t 39+ weeks gestation and changes in center of gravity.
Health change Increased acuity Status assessment reports r/t Premature Rupture of Membranes and Induction of Labor.
Pain level Normal acuity No contractions at this time.
Physiological Needs Increased acuity Status assessment reports r/t concern about situation and language barriers.

lOMoARcPSD|7393617

Sensorium Needs Normal acuity Quiet but alert and oriented, no indication of problems in status report.
Physiological

Acute Pain False No current pain; no contractions.
Chronic Pain False No history of chronic pain.
Injury, risk for True Status assessment reports r/t rupture of membranes.
Safety
Your
Fall Risk True Status assessment reports r/t shifting center of gravity at 39+ weeks gestation- thi
Injury, risk for fetal True Status assessment reports r/t risk for fetal hypoxia with induction.
Injury, risk for True Status assessment reports r/t risk for infection, uterine rupture, placental abruption
maternal labor.
Love and Belonging
Your
Anxiety True Status assessment reports r/t unknown impact of current situation on mother and fetus a
husband.
Deficient True Couple asking questions about induction of labor; first pregnancy and labor experience.
Knowledge
Disabled Family False No evidence. Husband accompanies.
Coping
Fear False No specific fears voiced; although the client and husband are anxious, there is no indicat
Spiritual Distress, True Status assessment reports r/t potential discrepancy between spiritual beliefs and prescri
risk for healthcare management, and privacy issues.

lOMoARcPSD|7393617
Scenario 1
Your Corre
orde ct
1 Wash hands and introduce self to the Washing hands upon entering the room is a priority for
client and her husband. prevention of infection. Introductions before touching the client
is professional behavior.
2 Ask client and her husband what they Use of first names and surnames vary among cultural groups,
prefer to be called. so nurses should not make assumptions, because of the use of
a person’s first name may be considered disrespectful. If the
person has a title, such as doctor, it should be used. The nurse
should ask what the person prefers to be called and record this
in the health record for future reference.
3 Ask if there is need for an interpreter Speaking and reading may not occur in the same language.
or translator and any specific privacy Interpreter is for oral communication and translator for written
needs during the assessment. words. Individuals should be asked about their privacy needs
and reservations related to touching, assessments, and gender
of the healthcare personnel.
4 Ask permission prior to touching the The appropriateness of touch varies with each culture.
patient. Obtain her vital signs, fetal Establish rapport with introductions and make sure client
heart tones, and perform a pain understands prior to touching her to obtain vital signs and fetal
assessment. Ask about time of heart tones. This action determines the stability of the mother
rupture of membranes and observe and fetus with a baseline. A change in status can often be
color of fluid. detected by a change of vital signs or fetal heart tones. Timing
of ROM and characteristics of fluid also should be assessed.
5 Educate client about the status of the Since the mother is anxious, reassurance can be given by
fetal heart tones. explaining what the nurse assessed about her baby.

lOMoARcPSD|7393617
Scenario 2
Your Corre
orde ct
1 1 Who do you want to be with Social class and cultural norms also affect these roles including specific
you in labor? roles for men and women. In the Muslim culture, women assume the
traditional role to bear children. Children are highly valued and
contraception is not used. Arabic families usually view the birthing
process as a female affair. Women defer to their husbands in decision
making. This first question addresses the first issue -presence during
labor.
2 2 What can your labor support Nurses should exercise sensitivity in working with every family, being
person do to help you be careful to assess the ways in which they apply their own mixture of
most comfortable during cultural traditions. This second question will clarify the role of the client’s
labor? husband.
3 3 What actions are important Nurses should ask questions about cultural or spiritual rituals at the time
for you and your family of birth or in the early newborn days which are a part of their belief
immediately after the system. Spirituality is a component of holistic nursing and thus a
baby’s birth? professional responsibility. Chronologically, this will be after delivery.
4 4 What do you expect from Nurses may be requested to provide the time and space for these rituals
the nurses caring for you to occur. There may prayers, spiritual rituals, or other actions during the
during the postpartum newborn and postpartum period.
period?
5 5 How will other members of Family roles involve the expectations and behaviors associated with the
your family participate in members position in the larger family system. These options are in order
the care of you and the new of the birth process and provide a chronological order for the questions.
baby once you go home?
Scenario 3

lOMoARcPSD|7393617
Your Corre
orde ct
1 1 Provide written information and instructions Husband prefers written instructions as he
about the induction of labor protocols to the understands English best in this format. Questions
husband. Allow the health care provider to should be referred to the healthcare provider and
explain the process and answer questions. Allow the nurse will reinforce the instructions. Client
the client’s husband to sign the consent on her agrees to allow husband to give consent for her.
behalf. Consent should be first in the plan.
2 2 Female health care providers only. Keep client Muslim religion prefers female health care providers
covered as much as possible and use non- for women due to modesty and privacy issues.
pharmacological comfort measures. Minimize Decreasing the number of vaginal exams decreases
vaginal exams for both comfort and to decrease exposure, discomfort, and risk for infection because
risk of infection. of rupture of membranes.
3 3 After birth, dry the newborn and allow the father Drying the newborn first prevents cold stress. While
to hold the baby briefly before placing skin to the father is holding the newborn, he can whisper
skin with mother. the prayers.
4 4 Assess 1-minute Apgar score while in father’s The Apgar score should be done at 1 minute and 5
arms and 5-minute score on mother’s abdomen- minutes. If the neonate is in need of resuscitation,
unless there is need for neonatal resuscitation. the parents will not be able to hold their baby until
the infant’s condition is stabilized. ABC’s come prior
to loving and belonging.
5 5 Allow mother to rub a soft date on newborn’s Combining their cultural custom with the date and
palate prior to feeding. Assist the newborn to breastfeeding should not have any negative impact
breastfeed within the first hour. on the newborn. Breastfeeding within the first hour
of life has been demonstrated to impact the success
of breastfeeding.
Scenario 4

lOMoARcPSD|7393617
Your Corre
orde ct
5 1 Assess fetal status with continuous When placental perfusion is diminished by contractions
electronic monitoring and that are too frequent or prolonged, the fetus can
evaluate/document every 15 minutes and experience hypoxemia and acidemia; eventually resulting
with every change of oxytocin dosage. in late decelerations and minimal or absent baseline
variability.
4 2 Assess contraction pattern and resting tone The goal of oxytocin use is to produce contractions of
every 15 minutes and with every change of normal intensity, duration, and frequency, while using the
oxytocin dosage; document. lowest possible dose of medication. As the dosage of
oxytocin is increased, the risk of uterine tachysystole,
fetal distress, and more cesarean births r/t fetal stress.
2 3 Initiate primary IV with Normal Saline The nurse implements the order by initiating the primary
solution. intravenous infusion.
3 4 Oxytocin 30 units/500 mL Normal Saline IV Oxytocin is a high alert medication because it has
through secondary line at 1 mu/min by heightened risk for causing significant client harm when
infusion pump at 1 mL/hr. Increase by 1-2 used in error. A solution of 30 units oxytocin in 500 mL of
mu/min, every 30-60 minutes, based on the solution allows for 1:1 administration and less risk for
woman, fetus, and progress of labor. error. Increasing the rate of infusion every 30 to 60
minutes is based on a half-life of 10-12 minutes and
approximately 40 minutes to reach a steady state of
oxytocin; for the full effect of the dosage increment to be
reflected in more intense, frequent and longer
contractions. Use of an infusion pump decreases risk for
error.
1 5 Assess BP, pulse, respirations every 30-60 Oxytocin use can present hazards to the mother including
minutes, and with every change of oxytocin placental abruption or uterine rupture. Changes in VS
dosage; document. would reflect these complications.
Scenario 5

lOMoARcPSD|7393617
Your Correc
orde t
2 1 Discontinue the Tachysystole is defined as more than 5 contractions in 10 minutes. When
oxytocin infusion. this occurs related due to stimulated labor, the nurse should immediately
discontinue the oxytocin infusion.
1 2 Reposition the client to Side lying position decreases pressure on the vena cava and increases
the other side. perfusion to the placenta and fetus. This intervention may be done quickly.
3 3 Administer oxygen via Enhance oxygenation to the fetus by administration of 100% oxygen to the
nonrebreather face mother. This intervention is quickly and may be done if the first two actions
mask at 10 L/min. are not effective.
4 4 Administer IV fluid Late decelerations do not return to baseline at the end of the contraction as
bolus of 500 mL/hr. a result of fetal hypoxemia. A fluid bolus will increase maternal BP and
perfusion to the fetus. This intervention is completed if the first 3 actions are
not effective to relieve tachysystole and fetal distress.
5 5 Administer terbutaline Terbutaline is a tocolytic to relax the uterine smooth muscle and relieve
0.25 mg tachysystole. This is the last action, if the other interventions do not relieve
subcutaneously. fetal distress.
Marcella Como

lOMoARcPSD|7393617
Your
Educational Increased Status assessment reports patient is a sexual trauma victim, taking HIV meds prophylaxis, social
Needs acuity worker with patient this morning.
Fall Risk Normal Status assessment reports no indication of fall risk
acuity
Health Change Increased Status assessment reports patient is a sexual trauma victim (rape), isolative, appears fearful/crying,
acuity taking HIV meds prophylaxis.
Pain Level Increased Patient is not complain of pain at this time.
acuity
Psychological Increased Status assessment reports patient is a sexual trauma victim (rape), isolative/fearful/crying, SANE
Needs acuity nurse and social worker with patient.
Sensorium Normal Status assessment reports no indication of increased psychological acuity
acuity
Scenario 1
Your Correct
1 1 Use therapeutic Using therapeutic communication to assess is first step to und
communication/Active Listening patient's psychological condition.
2 2 Full Assessment Full assessment is first step of establishes baseline of patient'
condition.
3 3 Provide emotional support After proper assessment, provide proper planning and interve
4 4 Documentation Document patient baseline assessment information for progre
Scenario 2
Your Correct
1 1 Use therapeutic Therapeutic Communication Assessment is first step to understanding pa
communication/Active request/concerns.

lOMoARcPSD|7393617
Your Correct
Listening
2 2 Educate patient Feeling of being "dirty" is common for rape victims.
3 3 Provide supplies and needed Demonstrates care for the patient. Patient may have questions regarding
instructions. surroundings.
4 4 Offer to Assist After receiving supplies and instructions patient may see obstacles wher
needed. Also, interaction could diminish feelings of abandonment, isolati
untouchability.
Scenario 3
Your Correct
1 1 Use therapeutic communication/Active Listening Listening to verbal & nonverbal messages f
2 2 Ask open-ended questions Allows more opportunity for discussion.
3 3 Seek clarification Narrows down open-ended questions.
4 4 Summarize discussion States main points & allows for further plan
Scenario 4
Your Correct
1 1 Restate or paraphrase patient Conveys listening & understanding of message.
statements
2 2 Acknowledge patient's decision Gives acceptance to wishes of patient after restating/paraphr
3 3 Review plan of action Marks beginning of next phase of POC.
4 4 Notify social services Notifying social services is next step of plan of action.
5 5 Document process Accurate documentation is to be performed after patient care
NEVER BEFORE!

lOMoARcPSD|7393617
Scenario 5
Your order Correct order Step Explanation
1 1 Review Labs Negative/positive test results will dictate Educatio
2 2 Educate Patient-STD's and pregnancy Education is achievable after understanding patien
3 3 Provide emotional support Nurse is to act as patient advocate and support pe
4 4 Discuss Support Groups Secondary issue designed to help victims with self
Ramona Stukes
Your
Educational Increased Status assessment reports NG tube possibly D/C'd, NPO with ice chips only.
Needs acuity
Fall Risk Increased Status assessment reports NG tube, Today's weight 226, IV left forearm, Pain medicine 2hrs ago at 1300,
acuity Ambulates with assistance.
Health Change Increased Status assessment reports patient is 3rd day post-op resection. NG tube possibly D/C'd. Today's incentive
acuity spirometry Tidal Volume is 1250ml…, NPO.
Pain Level Increased No indication of pain at this time
acuity
Psychological Normal Status assessment reports indication of increased psychological acuity
Needs acuity
Sensorium Normal Status assessment reports no indication of increased LOC acuity
acuity
Scenario 3

lOMoARcPSD|7393617
Your order Correct order Step Explanation

1 1 Full assessment Assessment is the first step of nursing process.
2 2 Educate patient Education is to be achieved after understanding patient c
3 3 Evaluate understanding Evaluation can be achieved after patient education is perf
4 4 Notify lead nurse and doctor Team should be notified of setback of treatment.
5 5 Consult Wound Care Treatment requires specialty personnel.
Scenario 4
Your Correct
1 1 Discuss with patient identify home health Assess patient's wishes and intent regarding dischar
needs
2 2 Notify lead nurse/doctor of new Doctor should be notified about situation for possible
circumstances treatment.
3 3 Contact Social Services for new consult Can be completed after doctor writes orders.
4 4 Update patient on discharge changes Inform patient of updates once attained.
Scenario 5
Your Correct
1 1 Follow HIPPA Protocol Patient information cannot be released.
2 2 Explain HIPPA Protocol Demonstrates consideration to caller.
3 3 Offer resource assistance to caller Gives caller options for assistance.
4 4 Contact Wound Care directly Wound Care can contact and assist patience with question
5 5 Document Conversation If it's not documented, IT DIDN'T HAPPEN!

lOMoARcPSD|7393617
Sarah Lane
Your
Educational Increased Status assessment reports anxiety regarding impending non-stress test and health of baby.
Needs acuity
Fall Risk Increased Client is 42 weeks pregnant and changes in center of gravity and balance increase risk for falls
acuity
Health Change Increased Status assessment reports post-term pregnancy: testing determines whether intrauterine envir
acuity to support fetus.
Pain Level Normal Status assessment does not indicate report of pain.
acuity
Psychological Increased Status assessment reports post-term pregnancy. Testing is used to determine timing of deliver
Needs acuity risk for uteroplacental insufficiency
Sensorium Normal Status assessment reports no indication of altered sensorium.
acuity

lOMoARcPSD|7393617
Your
Acute Pain False Status assessment reports no indication of pain.
Anxiety True Status assessment indicates previous pregnancy loss and current high-risk pregn
Bleeding False Stats assessment reports no indication of bleeding or risk for; NST is non-invasive
Infection, Risk False Status assessment reports no indication of infection risk; NST is non-invasive.
Risk for Fetal Injury True Status assessment indicates macrosomic infant, increasing risk for shoulder dysto
delivery.
Risk for Impaired Fetal True Status assessment indicates post-term pregnancy at 42 weeks gestation. Placent
Gas Exchange decreased affecting its ability to oxygenate fetus
Safety
Your
Deficient knowledge True Status assessment indicates woman and husband anxious regarding test an
Disturbed sensory perception False Status assessment reports normal sensory perception.
Fall, Risk for True Status assessment reports client is post-term in pregnancy, changes in cent
her at risk for falls.
Risk for Altered Family False Status assessment reports husband attending all prenatal visits.
Process
Risk for Ineffective Individual True Status assessment indicates previous pregnancy loss and current high-risk p
Coping pregnancy
Risk for Maternal Injury True Status assessment indicates NST to be performed; improper maternal positio
supine hypotension.
Saftey

Fall Risk True Status assessment reports r/t paresthesia in lower extremities.

lOMoARcPSD|7393617

Injury, risk for maternal False No indication
Physiological
Your
Acute Pain True Status assessment reports r/t perineal laceration.
Chronic Pain False Status assessment reports no history of chronic pain.
Ineffective breastfeeding, True Status assessment reports r/t risk decreased milk supply; “las dos cosas” (b
risk for bottle feeding).
Infection, risk for True Status assessment reports r/t perineal laceration.
Love and Belonging
Your
Deficient Knowledge True Status assessment reports First experience with postpartum, newborn,
breastfeeding.
Readiness for Enhanced True Status assessment reports Husband present; female family members pr
Parenting supportive.
Scenario 1
Your Correct
1 1 Wash hands and apply non-sterile gloves. Prevents nosocomial infection.
3 2 Review patient prenatal history with woman, confirming Care planning requires accurate, updated p
understanding of reasons for NST. and should be done prior to any care.
5 3 Have woman empty bladder. Provides patient comfort during procedure

lOMoARcPSD|7393617
Your Correct
4 4 Educate woman and husband on process of NST. Education allows for planning and impleme
care.
2 5 Obtain maternal Vital Signs. Establishes baseline maternal vital signs an
immediately prior to the test.
Scenario 2
Your Correct
1 1 Position patient in reclining chair (or Optimizes utero-placental perfusion by preventing supine hypo
semi-Fowlers position) with left lateral to vena cava compression and is the first step.
tilt.
2 2 Perform Leopold’s Maneuver. Identify position of fetus and location of fetal back to correctly p
tocodynamometer and the doppler transducer.
5 3 Apply doppler transducer to abdomen Detects and records FHR which is best heard through fetal back
over location of fetal back.
3 4 Apply tocodynamometer to uterine Detects and records uterine contractions or fetal movements.
fundus.
4 5 Teach patient to use handheld event If evidence of fetal movement not apparent on monitor tracing,
marker connected to monitor depresses marker when feels movement and it is recorded on t
final step in this scenario.
Scenario 3
Your Correct
1 1 Readjust woman’s position to opposite side, First, fetal movement is stimulated using maternal
ensuring lateral tilt and provide ice chips or small to ensure utero-placental perfusion; or ice chips or
amount of po fluids. simulate fetal movement.
4 2 Reassess maternal vital signs. Next, it is important to ensure absence of supine h

lOMoARcPSD|7393617
Your Correct
decreases utero-placental perfusion.
2 3 Palpate for fetal movement. Mother may not perceive fetal movements or unsu
depress event marker.
3 4 Adjust tocodynamometer and transducer. Proper placement of transducers facilitates accurac
and documentation.
5 5 Confirm patient understanding of procedure, Ensures patient cooperation and accuracy of testin
reassuring patient of fetal status. perceived fetal movements, FHR is reactive with m
variability.
Scenario 4
Your Correct
1 1 Reassess fetal position using Leopold’s Maneuver and Reassessment will be done first to ensure accura
placement of transducer. and documentation on monitor tracing.
2 2 Extend testing time for an additional 20 minutes. Based on reassessment findings, nonreactive te
evaluation; expectation is that fetal sleep state w
test will become reactive.
3 3 Educate patient and husband on the use of Uses a combination of sound and vibration to sti
vibroacoustic stimulation procedure. and alter fetal state
4 4 Monitor for 5 minutes before stimulation. To obtain a baseline FHR
5 5 If baseline remains nonreactive, activate vibroacoustic Desired result is a reactive NST which usually oc
stimulation device for three seconds on maternal minutes of stimulation.
abdomen over fetal head.
Scenario 5
Your Correct
2 1 Review monitor tracing and interpret NST results First, the nurse should assess para

lOMoARcPSD|7393617
Your Correct
a Reactive Non-Stress Test.
4 2 Consult with prescribing healthcare provider regarding assessment Collaboration with MD regarding a
findings and NST interpretation. interpretation of NST results; plann
care
1 3 Educate woman and husband on NST results. Education allows for planning and
of patient care
5 4 Schedule woman for follow-up NST (twice-weekly) if delivery has not To assess fetal status and determi
occurred. delivery.
3 5 Document performance of procedure, patient tolerance, and Accurate documentation is done a
collaboration with healthcare provider regarding interpretation of of patient care.
results.
Kenny Barrett
64 years old, was admitted for observation of initial administering of BP his treatment with blood pressure
of 220/124 after visiting his doctor for a routine physical. ECG was unremarkable. No past history of HTN.
Past medical history includes hyperlipidemia and a history of 1 pack a day smoker for the past 20 years.

lOMoARcPSD|7393617
Vital signs are Temp 98.9F, BP 178/90, P 88, RR 18 SaO2 95% on Room air. IV with NS @ 125 mL/ hr.
Patient has been complaining of a headache and dizziness. He is a patient of Dr. Adams.

Acute Pain True Patient has a headache.
Bleeding risk False Status assessment reports no indication of bleeding risk.
Safety
Your
Deficient knowledge True Patient doesn’t understand implications of hypertension and smok
Fall risk True Patient complains of dizziness.
Peripheral neurovascular dysfunction False Status does not indicate that this is present at this time, although
Scenario 1
Your Correct
1 1 Perform hand hygiene. CDC protocol to prevent spread of infection.
2 2 Re-assess blood pressure and pulse. BP is Re-assess as it is the nurses responsibility to ensure a

lOMoARcPSD|7393617
Your Correct
190/110, pulse is 86. pulse before medication administration.
3 3 Evaluate patients understanding of the Patient needs to understand the implications and side
medication and provide education. medication.
4 4 Administer the medication. Patient’s BP is within range to administer, as ordered.
5 5 Document on the MAR and education in the Documentation is the final step of medication adminis
chart. patient education must be documented in chart.
Scenario 2
Your Correct
1 1 Retake vital signs (BP is 110/70, pulse is 94). Assessment is in order as the patients health s
changed.
2 2 Instruct patient not to get out of bed without In order to prevent falls.
assistance.
3 3 Perform comfort measures. Reassures patient in order to reduce anxiety.
4 4 Request CNA to remain with patient. To prevent fall in case patient attempts to get
5 5 Notify the healthcare provider using SBAR. Change in health status requires notification o
Provider.
Scenario 3
Your Correc
order t order Step Explan
1 1 Patient Kenny Barrett is nauseated and complains of dizziness when they sit up. S : Situation – Stat
Patient, Problem.
2 2 Patient was admitted yesterday afternoon with hypertension, BP 178/90, pulse 88, B : Background – A
hypertension was undiagnosed and was started on Atenolol 50mg, once a day. This Diagnosis, Pertinen
is his second dose. IV 20 gauge, left forearm NS 125ml/hr. treatments.
3 3 Current vital signs are BP:110/70, Pulse: 94. Patient is pale, dizzy, and nauseated. A : Assessment – C

lOMoARcPSD|7393617
Your Correc
order t order Step Explan
Physical assessme
4 4 Request possible change in medication and more frequent vital signs. R : Request – Need
evaluation, Further
to higher level of c
Scenario 4
Your Correct
order order Step Explanatio
1 1 Take vital signs now and Q4 hours. Vital Signs are the priority a
2 2 Maintain strict I&O. Patients fluid volume status
3 3 500 mL normal saline bolus. Isotonic solution to increase
4 4 Hold next dose of Atenolol if BP is <130/80. Hold next dose if patient is
5 5 Contact Healthcare Provider if patient status does not improve. Further treatment may be n
Scenario 5
Your Correct
1 1 Assess stress level. Determine stress level in order to provide appropr
intervention(s).
2 2 Communicate with the patient therapeutically Patient is in moderate stress, therapeutic commun
escalate patient.
3 3 Discuss willingness for alternatives to smoking. Determine options that patient would be willing to
4 4 Educate patient to why he cannot go outside Patient is a fall risk due to current condition.
and smoke.
5 5 Contact Healthcare Provider for Nicotine patch Order is needed to provide patient with an alterna
order.

lOMoARcPSD|7393617
Renee Wilson
26 y/o G1P0 admitted four hours ago to the Birthing Center. She has had an uncomplicated pregnancy, but
her obstetrician has expressed the concern about needing a c-section because of the anticipation of a
large baby. Her last ultrasound estimated fetal weight at 9 lbs. 6 oz. She and her husband have attended
Lamaze Prepared Childbirth Classes and their Birth Plan includes the desire to have an unmedicated labor
and vaginal birth. She also desires skin to skin contact with her baby at birth and breastfeeding. Admit
assessment findings: Sterile vaginal exam (SVE) - 4 cm, 80% effaced, and fetal vertex at a -2 station with
intact membranes, slight bloody show. BP 110/70 mmHg, P. 88 beats/minute, R 24 breaths/minute; T 98.8
F. 37.1 C. FHR 150 baseline with moderate variability + accelerations, absent decelerations (Category 1).
Contractions are occurring every 2 minutes, lasting 60 seconds with moderate intensity per palpation.
Portable tocodynamometer and fetal ultrasound transducer are in place. She is using shallow-chest
breathing and conscious relaxation techniques and is ambulating in her room. She rates her pain at 5/10.
She tells you that she will feel like a failure if she can’t deliver vaginally.
Acute Pain True Status assessment reports frequent contractions, use of breathing techniques and r
5/10.
Anxiety Fals Status assessment reports potential for caesarean-section and woman desiring an u
e vaginal birth.
Bleeding True Status assessment indicates just a slight bloody show consistent with active labor.
Imapired mobility Fals Status assessment reports woman ambulating in room, ambulation may facilitate la
e
Impaired patterns of Fals Status assessment indicates active labor which can impede ability to empty bladde
elimination e
Infection, Risk for Fals Status assessment reports a large fetus with possible dystocia and prolonged labor.
e
Nausea Fals Status assessment does not indicate increased risk for nausea.
e
Safety

lOMoARcPSD|7393617
Your
Deficient Knowledge False Status report indicates attendance at childbirth classes but each labor diff
variety of coping skills and education.
Fall, Risk for False Status assessment reports woman ambulating in room and changes in pre
may increase for falls.
Impaired maternal newborn True Status assessment reports potential for an undesired C-Section with perce
bonding, Risk for failure.
Risk for fetal injury False Status assessment reports fetus at -2 station despite active labor and freq
contractions.
Risk for Ineffective Coping True Risk assessment reports minimal family support; patient visibly upset.
Risk for Situational Self Esteem True Status assessment reports potential feelings of failure if C-section require

lOMoARcPSD|7393617
Scenario 1
Your Correct
2 1 Discuss C-Section as an alternative method of Allays fear of being weak or a failure and that only
childbirth. delivery is considered “normal”.
3 2 Allow the woman to verbalize feelings and thoughts Can be used to focus nursing care and education n
regarding potential for C-section.
4 3 Praise woman and husband for efforts in use of Boosts self-esteem and supports them in their Birt
non-pharmacologic labor techniques.
5 4 Encourage frequent position changes and Comfort and relaxation measures; facilitates progr
hydrotherapy in shower.
1 5 Suggest changing to a more complex breathing Requires increased alertness and concentration th
technique since pain is rated at 5/10. painful stimuli than simpler breathing patterns.
Scenario 2
Your Correct
5 1 Assist woman to bed; reassess FHR baseline Spontaneous rupture of membranes with a high station
and reactivity. prolapsed cord; indicates tolerance to labor process. Fet
critical.
2 2 Using a sterile gloved hand, test fluid leaking Nitrazine paper differentiates amniotic fluid need space
from vagina with Nitrazine paper. from urine (acidic). Needs to occur next.
1 3 Assess color and character of amniotic fluid. Amniotic fluid should be clear with no foul odor; meconi
indicative of potential alterations in fetal response to lab
3 4 Assess contraction pattern and palpate uterine Assess labor progress and intensity of contractions.
resting tone.
4 5 Reassess maternal vital signs, including Monitors physiological response to labor; risk for infectio
temperature; assess temperature every two
hours.

lOMoARcPSD|7393617
Scenario 3
Your Correct
4 1 Reassess maternal and fetal status every 15 To determine contraction pattern and the need to a
minutes and with each dose change of oxytocin. rate; FHR must be reassuring to increase oxytocin
3 2 Encourage her to void at least every two hours, Avoid bladder distention which can impede fetal de
assessing intake and output. comfort.
2 3 Assist her with peri-care and change underpads as Provides comfort and prevents infection.
needed.
1 4 Teach husband how to apply counter-pressure to Relieves back pain that may be associated with fet
woman’s back during contractions while sitting on position; encourages pelvic mobility and perineal re
birthing ball. encourage fetal descent.
5 5 Continue to provide comfort measures and minimize Decrease discomfort and aid in focus on non-pharm
distractions in room. techniques.
Scenario 4
Your Correct
1 1 Assess FHR before removing transducer; cleanse abdomen Document fetal status prior to beginning
with chlorhexidine wipes. kills bacteria on skin that can cause infec
3 2 Insert Foley catheter. Keeps bladder empty to prevent damage
delivery.
4 3 Apply sequential compression device (SCD) boots to calves; Prevents blood clot formation; ensures sa
secure legs to OR table with strap. positioning.
2 4 Perform lap, needle and instrument count with OR tech prior Establishes baseline count to ensure noth
to start of case and at established intervals. patient.
5 5 Perform Time-Out. Confirms patient identity, procedure perfo
presence of appropriate personnel.
Scenario 5

lOMoARcPSD|7393617
Your Correct
3 1 Assist in drying infant and place on a pre-warmed Prevents evaporative and conductive heat loss.
radiant heat warmer.
2 2 Perform Apgar Score at 1 and 5 minutes of age. Rapid assessment of newborn’s transition to extr
based on five signs that indicate newborn’s phys
1 3 Assess vital signs; perform brief physical assessment. Assesses physiologic stability; cursory assessme
disposition of infant.
4 4 Place matching ID bands on infant, mother and Safety feature to ensure correct, on-going identi
father. and parents.
5 5 Place infant skin-to-skin on mother’s chest with father Provides neonatal temperature stabilization; pro
at her side; cover infant with warm blanket. infant bonding and stimulates early lactation beh
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.
Your
Acute Pain False Status assessment reports r/t current abdominal pain.
Chronic Pain False No history of chronic pain.
Decreased Cardiac False Not enough evidence in assessment at this time (would be at risk for). Client is aler
Output history during admission intake.
Deficient Fluid Volume, False Blood loss r/t vaginal bleeding.

lOMoARcPSD|7393617
Your
risk for
Ineffective Tissue False Not enough evidence in assessment at this time (would be at risk for).
Perfusion
Injury, risk for fetal True Status assessment reports r/t risk for fetal hypoxia related to potential complication
Safety
Your
Fall Risk False Status assessment reports r/t shifting center of gravity at 34 weeks gestation- thir
pain.
Injury, risk for True Status assessment reports r/t risk for hypovolemia from hemorrhage.
maternal
Love and Belonging
Your
Anxiety True Status assessment reports r/t unknown impact of current complication on mother and fe
Disabled Family False No evidence. Husband accompanies. Contacted neighbor for care of older children temp
Coping contacting family.
Fear True No indication of fear at this time.
Grieving False Status assessment reports r/t actual or perceived threat to self, pregnancy, and infant. U
from previous pregnancy loss often resurfaces during further pregnancy especially if com
Health False Status assessment reports r/t deficient knowledge about high risk pregnancy.
Maintenance;
Ineffective
Scenario 1
Your Correct

lOMoARcPSD|7393617
Your Correct
2 2 Obtain her vital signs, The first action should be determining the stability of the mother and fetus. A c
fetal heart tones, and can often be detected by a change of vital signs or fetal heart tones.
perform a pain
assessment.
3 3 Educate client about the Since the mother is anxious, reassurance can be given by explaining what the
status of the fetal heart about her baby.
tones.
4 4 Apply gloves and assess The degree of vaginal bleeding is an important part of the nurse’s assessment.
perineal pad for bleeding. of private areas should be performed later in the examination if the client is sta
assessing for vaginal bleeding, ask the client to lift her bottom completely off t
the nurse can observe for blood loss beneath the buttocks.
5 5 Ask the client not to get Before leaving the room, the nurse should assess and intervene for safety, plac
out of bed without in reach and teaching about the risk for injury.
assistance.
Scenario 2
Your Correct
1 1 Maintain bedrest/side-lying Left lateral recumbent position decreases pressure on vena cava, therefore in
position. return, placental and renal perfusion. Fetal safety is a priority.
2 2 Obtain CBC, Chemistry This will assess vital information about fetal status. Contact the lab to come an
Panel, Ultrasound/ labs. The results of the lab will take several minutes and will drive the plan of
Biophysical profileUS/BPP. client. US will differentiate placenta previa and abruptio placenta. Biophysical
fetal status.
6 3 Provide continuous EFM, Initial VS were recorded on admission. With history of chronic HTN and gestati
vital signs q 15 minutes. at risk for preeclampsia and eclampsia. Deviations in client’s baseline VS could
intravascular fluctuations related to third trimester bleeding. Client is concern
Hearing fetal heart will decrease client’s anxiety prior to taking her VS. Verifie
EFM has been in place but US and tocotransducer may need to be adjusted aft

lOMoARcPSD|7393617
Your Correct
onto her left side.
3 4 Insert IV 18 gauge, infuse At least one IV (large bore in case blood transfusion is necessary) to replace fl
Lactated Ringer’s at 150 blood replacement prn.
mL/hr.
4 5 Administer IM Administer the IM steroid injection to enhance fetal lung maturity for gestation
betamethasone 12 mg q24 weeks. Neonatal benefit is maximized when the interval between the first inje
h x2. longer than 48 hours. The benefit of one injection is unknown but not harmful.
5 6 Administer Rh This client is Rh positive so she is not a candidate for RhoGAM. Clients who are
immunoglobin 300 mcg IM. would receive the Rh immunoglobin to prevent formation of D antibodies in m
case there was an exchange of fetal D antigens into maternal circulation durin
of the placenta.
Scenario 3
Your Correct
6 1 Maintain bedrest. This is a priority because the client is actively bleeding so bedrest
maintained. Movement could disrupt clot formation and hemostas
1 2 Bring extra pillows to enhance comfort Enhancing comfort in the side-lying position will enable the client
in side-lying position and place position. Side-lying decreases pressure on the vena cava, increase
between knees, behind back, and placental and renal perfusion. Safety for mother and baby.
under abdomen.
4 3 Bring scale into room and weigh all Weighing pads most accurately determines blood loss. Each gram
pads. weight) equals 1 mL of blood loss.
2 4 Bring bedpan and graduated cylinder The nurse may include I&O in the care plan independently. At leas
into room. urine output demonstrates minimal kidney function. Left lateral po
renal perfusion. Blood loss would be documented as output. 24 ho
documents positive or negative fluid balance.
3 5 Educate client and significant other Educating and involving the client and husband in the plan of care
about I&O and documenting oral decrease anxiety and empower them as important members of th
intake. team. Education occurs after other physiological needs are met.

lOMoARcPSD|7393617
Your Correct
5 6 Conduct a vaginal exam to assess Vaginal exams should not be done as the examiner’s fingers could
labor progress. and disrupt clot formation. This client does not show signs of activ
imminent. Vaginal exam is contraindicated by the nurse. This inte
not be completed.
Scenario 4
Your Correct
3 1 Teach that if bleeding resumes, return The abruption of the placenta can extend at any time. The client
to the hospital immediately. recognize this situation and return immediately to the hospital. S
2 2 Teach the client to keep all To assure maternal and fetal well-being with a mild-moderate abr
appointments for prenatal visits, fetal consistent surveillance will be needed. Appointments should be g
assessments, and lab tests. prior to discharge and will monitor fetal and maternal status.
1 3 Ensure the client lives within a short For this client to be discharged to home, she must meet these cri
distance from the hospital and has should be advised to call 911 for any emergency situation.
constant access to transportation.
5 4 Discuss willingness to comply with Bedrest will be challenging with two other children. She will need
activity restrictions: bedrest with increase compliance with activity restrictions. “Pelvic rest” needs
bathroom privileges and “pelvic rest”. as no intercourse, no douches or tampons, no fingers or toys, not
the vagina.
4 5 Discuss diversionary activities and Once stabilized, this client will feel generally well and boredom w
provide resources for coping with restrictions is common. Ideas for diversional activities and suppor
bedrest. assist the client in remaining compliant with activity restrictions.
Scenario 5
Your Correct
1 1 Call for assistance (other nurses, Staying with the client develops trust so they don’t feel abandon
healthcare provider) but do not leave for client safety. Fear and anxiety will decrease when the client i
client. Keep family/partner informed of health status; reduces the fear of the unknown. Anxiety is highly
situation. Give emotional support. extremely important the nurse remains calm and provides emot

lOMoARcPSD|7393617
Your Correct
the family.
2 2 Obtain her vital signs, fetal heart tones, The first action should be determining the degree of stability of t
and perform a pain assessment. baby. A change in status can often be detected by a change of v
heart tones.
4 3 Administer oxygen via non-rebreather Enhance oxygenation to the maternal vital organs and the fetus
mask at 10 L/min. of 100% oxygen. This action helps both clients quickly. It takes m
an IV and insert an indwelling urinary catheter.
3 4 Insert 18 gauge IV and infuse Normal At least one IV (large bore in case blood transfusion is necessary
Saline or Lactated Ringer’s boluses. loss and for blood replacement prn.
5 5 Insert indwelling urinary catheter. Continuous measurement of urinary output is an excellent indire
of maternal organ perfusion. A catheter also keeps the bladder e
prepares the client for cesarean birth if necessary. Catheter may
the operating room if a c-section is imminent. Immediate birth is
of choice if the fetus is near or at term and bleeding is moderate
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.
Acute Pain False

Anxiety True
Impaired mobility, risk for True
Impaired patterns of elimination False

lOMoARcPSD|7393617
Infection, Risk for True

Nausea False
Deficient knowledge True
Disturbed sensory perception False
Fall, risk for True
Risk for injury, maternal/fetal True
Scenario 1
1.) Establish therapeutic communication; review prenatal history with woman and events leading her to present to triage.
2.) Assess vital signs, including temperature.
3.) Perform Leopold's Maneuver.
4.) Apply external tocodynamometer and fetal transducer and palpate fundus to assess for contractions.
5.) Using a sterile gloved hand, test fluid leaking from vagina with Nitrazine paper.
scenario 2
1.) Place bed in Trendelenburg position.
2.) Discuss plan of care with patient; answer questions honestly, especially concerning SROM and implications for
preterm labor and birth.
3.) Assess support systems available to woman.
4.) Apply sequential compression device (SCD) boots and connect to machine.
5.) Begin Intake and Output (I&O) chart and document every shift.
Scenario 3
1.)Inspect perineum.
2.) Assess FHR for bradycardia.
3.) Assess vital signs, including temperature.
4.) Assess for contractions; palpate fundus.
5.) Assess for foul odor to amniotic fluid; perform pericare and provide fresh underpads.
Scenario 4
1.)Perform Non-Stress Test (NST) now and bi-weekly BPP and every shift; teach woman to do Daily Fetal Movement
Counts (DFMCs).
2.)Administer Betamethasone 12 mg IM for two doses 24 hours apart.

lOMoARcPSD|7393617
3.)Administer a broad-spectrum antibiotic (e.g., ampicillin, erythromycin) and continue for 7 days.
4.)Request neonatologist to visit patient.
5.)Assess results of daily CBC.
scenario 5
1.)Encourage vocalization of fear and concerns.
2.)Cluster nursing care activities as much as possible, such as medication administration, assessments, and vital signs.
3.)Offer diversional activities: watching TV, reading, crossword puzzles, small needlecraft activities. Request family to
bring articles from home to "decorate" hospital room.
4.)Teach conscious relaxation and breathing techniques.
5.) Provide comfort measures such as back rubs, position changes, and aromatherapy.

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lOMoARcPSD|7393617

Med Surg 2 (West Coast University)

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You responded correctly to 5 out of 6 evaluations:

Category Your response Explanation

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You responded correctly to 6 out of 6 evaluations:

Category Your response Explanation

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1 Explain all plan of Explanation of plan of care

Elevate Her DTRs are +3 so she is slightly

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a seizure. Safety first!

1 Educate the client Actively involving client in their

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about the opportunity for verbal consent of

Turn head to one Keep airway patent and

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Keep family informed of watch.

1 Assess vital Assess post-seizure status of both

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1 Review prenatal record It is the responsibility of each

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Anesthesiologist orders, epidural available to correct hypotension. Hypotension reduces

1 Educate patient Epidural analgesia decreases

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Turn Stops infusion of epidural

1 Continually monitor Allows for continual assessment of

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Follow-up on Even though requests are made

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4 on a patient. medical record is a legal document and will be used against

You responded correctly to 5 out of 6 evaluations:

Category Your response Explanation

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assessment. Should be done on entering the room.

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prescribed. Practice depends upon agency policy.

Renee Workman, blood work Situation

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rate would you like to start

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potential need for catheterization.

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1 Use therapeutic communication/active Active listening allows patient to express

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