NCM 109 Case # 4

OB CASE:

 You are the nurse assigned in the delivery

room of Fabella Memorial Hospital from
6-2PM shift. Suddenly, the phone rings “
Admission from ER, a 30 year old female
G6P5. ” Hence , you prepare the labor
room for admission”
ENDORSEMENT FROM THE E.R
NURSE

“ENDORSING THIS 30 YEAR OLD

FEMALE, G6P5,34 weeks AOG

WITH CHIEF COMPLAINT OF

“Nurse, I think my water broke”
Internal Exam Result
done in ER
cervix=4-5cm dilated
effacement=50%
effaced
BOW (-)
with moderate
bleeding noted
Patient also verbalized
“My water broke 3
hours ago”
 Hematology Reference Values Patient’s Results /Interpretation
Hgb Female:12-16g/dl 12g/dl

Laboratory
Hct
WBC
Female:36-46%
Adult:5,000-10,000
38%
15,000
Results:
RBC Female:4.0-5.0 4.5
Platelet 150,000-400,000 200,000
Hematocrit 36-46% 38%
Blood Type B+
 URINALYSIS Patient’s Result
COLOR Slightly Turbid
pH 6.0
Laboratory
Specific Gravity 1.0
Result
Protein
Glucose
negative
negative
Pus cells 15-20

Red cells 5-10

Mucus Threads moderate
Bacteria Few
  1.Vital signs monitoring hourly esp cardiac rate
 2.Monitor and record uterine contractions
 3.Hook patient to a fetal monitor
 2.IVF D5LRS 1L @ 30 gtts/min
 3.CBC w/blood typing=blood extracted, results for follow up
Doctor’s  4.Routine Urinalysis=Urine specimen sent to lab and for urine
Order:Upon culture

admission  5.Medications: Give Betamethasone 12 mg IM for 2 doses @ 24

hours apart
 Start on Ampicillin 1 gram as loading dose ANST(-)
 6. CBR w/o BRP’s
 7. Avoid heavy meal but keep patient hydrated at all times
 8. Notify Neonatal Intensive Care Unit
Patient hook to
fetal monitor
 RESULT:
Contractions @
5-10 minutes
interval
 FHT=150
beats/minute
 moderate to
strong in
intensity