Caring for a patient in OB 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 Assessment
• Nurses’ Notes4/01/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.
• Vital Signs
• Laboratory Results

Question 4 of 6

Nurse is reviewing the provider’s orders in the EMR. Based on the current status of the patient, determine which orders the nurse will be implement at this time in the PACU. Be sure to drag (select) all that apply.

• Remove the Foley catheter
• Continue LR at 125 mL/hr with oxytocin per protocol
• Encourage deep breathing
• Advance diet to liquids
• Provide Foley catheter and perineal care
• Discontinue SCDs
• Continue weighing pads and chux to calculate QBL
• Encourage ambulation

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

Davis Advantage for Maternal-Newborn Nursing: The Critical Components of Nursing Care Third Edition

by Roberta Durham RN PhD (Author), Linda Chapman RN PhD (Author)