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.
Question 5 of 6
The nurse is assessing the patient. Select to highlight the current assessment findings that indicate the patient is having a postpartum complication. Select all that apply.
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.
Temp 100.6°F (38.1°C)
HR 108 beats/min; regular
RR 22 breaths/min
SpO2 100% on room air
Blood pressure 101/64 mm Hg
Pain 5 on 1-10 scale, abdomen and urethra.
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/.