Triage in Active labor

The nurse is caring for a patient in OB triage in active labor. Use the chart to answer the questions. The chart may update as the scenario progresses.

• History and Physical AssessmentMedical/Surgical history: Patient is a 29-year-old African American female, G4P2012, at 39.5 weeks. EDD is 4/03/XX based on first trimester ultrasound. Patient is compliant with prenatal appointments and care recommendations, and has had no complications with pregnancy.
  • First pregnancy 5 years ago: IVF pregnancy. SVD at 40.3, first degree laceration, no other complications, 3,285 g viable female.
  • Second pregnancy 3 years ago: IVF pregnancy. SVD at 38.6 weeks, no complications, 3,420 g viable male.
  • Third pregnancy 18 months ago: IVF pregnancy. SAB at 10 weeks, unknown pathology.
• Social history: Nonsmoker, nondrinker, no history of drug use. Is an elementary school teacher. States marriage is stable and happy with no concerns. Wife is an active-duty naval officer, currently deployed in the Mediterranean. Has family in the area for support, including two sisters and her parents.
  Family History: Maternal and paternal history of hypertension. Paternal hyperlipidemia. Maternal depression, well controlled with medication. No other concerns.
  Physical Assessment: Pre-pregnancy—height 5’11”, weight 168 lb, BMI of 23. Current weight 194 lb. NST is reactive, FHR baseline 140 bpm with contractions every 2 to 4 minutes, moderate intensity on palpation. SVE 5/80/0, membranes intact.

4/01/XX
1428
Patient ambulated to OB triage with sister at her side. States contraction pain woke her around 0630 this morning, but labored at home until they became more frequent.
1450
Provider contacted with report and recommendation for admit. Patient admitted to labor and delivery unit per provider orders. Patient ambulated to room, oriented to room and care plan. Placed on FHM, US above umbilicus on the right side. 18-gauge INT placed in RFA (right forearm), CBC and type cross labs drawn and sent to lab.
1510
Patient states she felt a gush of fluid during a contraction. Pericare performed. Fluid noted to be clear and copious.
1528
Patient states she feels the urge to push. Provider notified and room prepared for delivery.
1532
Provider at bedside. Patient is open glottis, involuntarily pushing. Tarry, black discharge is noted at the vaginal introitus. The provider palpates the presenting part, and calls for an urgent cesarean section.
1541
Patient transferred to OR bed. Anesthesia provider assessing and preparing to place patient under general anesthesia as surgical technician and nurse prepare patient for procedure.
1618
Patient transferred to PACU. Patient beginning to wake from general anesthesia. Sister is at bedside holding infant skin to skin.
1633
Patient is still rousing, but able to verbally respond. Patient is suffering from pruritus as evidenced by unconscious scratching of face and arms. 12.5 mg diphenhydramine administered at this time. Fundal height is +2 cm above umbilicus, lochia is moderate to heavy. Bright red blood is noted in Foley collection bag. Bowel sounds are absent. Provider notified of unexpected findings.
1640
Patient begins to cry. States, “I’m upset I had a C-section. My last baby, and it had to be a C-section.” Sister at bedside offering comfort and shows patient the infant. Patient begins to calm and affect improves.
1642
Provider at the bedside to assess patient. Orders to continue with current care interventions and assessments. States postoperative orders will be placed into the patient’s EMR.
1648
Infant placed skin to skin, and then to breast. Fundal height is 1 cm above umbilicus, lochia small. Bowel sounds hypoactive in all four quadrants. Incision dressing remains dry. Patient states she feels tired, but is alert X4. Foley collection bag emptied into graduated cylinder, 360 mL of blood-tinged urine.
1728
Patient transferred to postpartum unit, bedside report given to postpartum nurse.
2130
Nurse at bedside to assist patient with ambulation and notes serosanguineous drainage on the patient’s abdominal bandage. Patient states she feels like she can’t get warm. Fundal height is at umbilicus, firm, and midline. Lochia is scant and rubra. Urine in Foley collection bag is pink and cloudy. 320 mL emptied using graduated cylinder.
4/03/XX
1430
Patient has completed her prescribed IV antibiotics, INT removed. Pharmacy to bring oral antibiotics, iron supplementation, and ibuprofen to room. Patient has discharge orders in EMR from provider. Follow up appointments for both the provider and the mother’s preferred pediatrician have been made.
1447
Nurse at bedside reviewing discharge instructions with patient.

Question 6 of 6

The nurse is at the bedside giving discharge instructions to the patient. Complete the sentences.
Patient verbalizes understanding to come to the emergency room if she _________________________
Select
A) has scant bleeding over the next several days
B) has issues with sleep and is persistently sad
C) has diaphoresis and diuresis has cramp-like afterpains .

Patient also verbalized the need to bring the infant to the emergency room if they _______________________________________
Select:
A) have watery, green stools
B) have yellow, seedy stools
C) are waking every 2 to 3 hours fussing and sucking on hands
D) cry at random times until picked up or fed .

https://platform.davisadvantage.com/maternal-newborn/dcj/intrapartum-and-postpartum-care-cesarean-section-b/

Durham, Roberta. “Intrapartum and Postpartum Care of Cesarean Section Birth Families: Clinical Judgment Assignment.” F. A. Davis, https://platform.davisadvantage.com/maternal-newborn/dcj/intrapartum-and-postpartum-care-cesarean-section-b/.