Maternity Case 4: Carla Hernandez

Documentation Assignments

1. Document your initial assessment data for Carla Hernandez, including fetal
heart rate activity (baseline fetal heart rate, long-term variability,
accelerations, and decelerations) and maternal vital signs.

32 year old female, no known allergies. G2P1, at 39 5/7 weeks of gestation. In

active labor at 0600 hours, accompanied by husband. Pt status: A&O x4, HR
90, BP 137/82, SpO2 98%, FHR 89, bradycardic, recurrent late decelerations
with declining variable, showing sinusoidal pattern; Category III; abnormal
FHR. Pt given 500 mL bolus of Lactated Ringers, FHR decreased to 72 bpm.
Vaginal exam performed, prolapsed umbilical cord. Pressure relieved by nurse
using sterile glove hand. Pt given 0.25 subq terbutaline. Provider called.
Prepped pt for cesarean.

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

500 mL bolus of Lactated Ringer’s

0.25 subq Terbutaline

3. Document your situation-background-assessment-recommendation (SBAR)

communication to Carla Hernandez’s provider and note any provider orders
that were obtained during this simulation activity.

Hello, I’m calling from L&D about Carla Hernandez, 32 year old female in
active labor. Her membranes were ruptured artificially and the FHR has since
decreased to 72 bpm. She was given 500 mL Lactated Ringers and 0.25 subq
terbutaline. Vaginal exam performed, showing prolapse of umbilical cord,
pressure relieved. Recommendation is for the pt to have a C/S.

4. Document the time that the umbilical cord prolapsed during this simulation
and the nursing interventions that were taken, including the timing. Note an
evaluation of the effectiveness of these measures in resolving the problem
identified, and the times that the provider was notified.

The umbilical cord prolapse was noted at 0714, nonrebreather mask at

10L/min applied, 500 mL bolus of Lactated Ringer’s infused. Pressure relieved
by pushing away the presenting part from the umbilical cord using sterile

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 gloves. Pt was repositioned into Trendelenburg. Actions helped elevate FHR to
107bpm.

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

FHR 72bpm, bradycardia, recurrent late decelerations with variable

deceleration, showed sinusoidal pattern. Intervention enacted increased FHR
to 105bpm.

6. Record the communication that was expressed to Carla Hernandez’s

husband, Earl.

Earl was made aware that the baby was not receiving enough oxygen which
is an emergent situation and required immediate attention, as well as a C/S.

7. Document how the health care team worked together during this simulation
and state your recommendations for improvement.

The provider was made aware of the situation. Also, surgery/OR, NICU, and
anesthesia were made aware and were expecting the arrival of Carla for an
immediate and unscheduled C/S. I don’t believe any improvements could
have been made, I believe the simulation was portrayed well.

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