Health Care > QUESTIONS and ANSWERS > Renee Wilson, 26 y/o G1P0 admitted four hours ago to the Birthing Center/ Renee Wilson maternal ALL (All)
Renee Wilson, 26 y/o G1P0 admitted four hours ago to the Birthing Center. She has had an uncomplicated pregnancy, but her obstetrician has expressed the concern about needing a c-section because o... f the anticipation of a large baby. Her last ultrasound estimated fetal weight at 9 lbs. 6 oz. She and her husband have attended Lamaze Prepared Childbirth Classes and their Birth Plan includes the desire to have an unmedicated labor and vaginal birth. She also desires skin to skin contact with her baby at birth and breastfeeding. Admit assessment findings: Sterile vaginal exam (SVE) - 4 cm, 80% effaced, and fetal vertex at a -2 station with intact membranes, slight bloody show. BP 110/70 mmHg, P. 88 beats/minute, R 24 breaths/minute; T 98.8 F. 37.1 C. FHR 150 baseline with moderate variability + accelerations, absent decelerations (Category 1). Contractions are occurring every 2 minutes, lasting 60 seconds with moderate intensity per palpation. Portable tocodynamometer and fetal ultrasound transducer are in place. She is using shallow-chest breathing and conscious relaxation techniques and is ambulating in her room. She rates her pain at 5/10. She tells you that she will feel like a failure if she can’t deliver vaginally. You responded correctly to 5 out of 6 evaluations: Category Your response Explanation Educational Needs Increased acuity Status assessment reports she is a G1 having attended childbirth classes, but first-time mothers require focused education and reinforcement of concepts learned. Fall Risk Increased acuity Health change Increased acuity Status assessment reports she is pregnant and is experiencing changes in balance and center of gravity. Patient is in labor and is experiencing a change in health status. Category Your response Explanation Pain level Increased acuity Status assessment reports pain scale of 5/10 and using non-pharmacologic pain management techniques. Physiological Needs Sensorium Needs Normal acuity Normal acuity Status assessment reports active labor at 5 cm dilation; potential c-section due to fetal macrosomia. Status assessment reports no indication of altered sensorium. You correctly diagnosed 11 out of 13 options: Physiological Description Your Response Explanation Acute Pain True Status assessment reports frequent contractions, use of breathing techniques and report of pain 5/10. Anxiety True Status assessment reports potential for caesarean- section and woman desiring an unmedicated vaginal birth. [Show More]
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