Stephanie Gold Room 303

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Stephanie Gold Room 303 Stephanie Gold, 19-year-old Caucasian female, G1 T0 P0 A0 L0, 32 weeks gestation. Uncomplicated pregnancy except for anemia treated with PO iron. States 3 times in last week... has called on-call obstetrician about fatigue, body aches, mild nausea during the evening. The client reports, “I don’t feel well, I haven’t vomited, but nausea makes me not want to eat too much. I am drinking ok, just want to eat bland foods.” Rest and acetaminophen were recommended. Client is first-year nursing student and states several students have had a “GI bug”. States during day felt better and went to school all but one day. No fever. She stated: “Can’t be absent from nursing school!” No contractions, leaking of fluid or vaginal bleeding. Came in this morning (Saturday) due to pain by right rib cage. States this is new today. Boyfriend accompanies client. You responded correctly to 5 out of 6 evaluations: Category Your response Explanation Educational Needs Increased acuity Status Assessment reports r/t change in condition Fall Risk Normal acuity Status Assessment reports r/t physiological shifts of pregnancy/center of gravity Category Your response Explanation Health Change Increased acuity Status Assessment reports r/t malaise/nausea/pain during pregnancy Pain Level Increased acuity Status Assessment reports r/t right upper quadrant pain Psychological Needs Increased acuity Status Assessment reports r/t concern about her baby’s health/her health and absence from nursing school Sensorium Normal acuity Status Assessment reports no indication in report that there is a change in sensorium Physiological Description Your Response Explanation Deficient Fluid Volume True Status assessment reports no generalized edema from fluid shift from intravascular to extravascular at this assessment/nausea not significant enough to cause deficit. Imbalanced Nutrition False Status assessment reports assessments do not show nutrition has been substantially impacted by slight nausea. Injury, risk for fetal True Status assessment reports r/t risk for uteroplacental insufficiency secondary to vasospasm if abdominal pain and malaise/elevated BP indicate preeclampsia/HELLP syndrome. Injury, risk for maternal True Status assessment reports r/t hypertension and vasospasm and potential decreased renal perfusion. Nausea True Status assessment reports experiencing slight nausea off and on this week. Safety Description Your Response Explanation Fall Risk True Status assessment reports r/t shifting center of gravity at 32 weeks gestation and in the third trimester. Injury, risk for maternal True Status assessment reports r/t risk for worsening preeclampsia to eclampsia and seizures. Love and Belonging Description Your Response Explanation Anxiety True Status assessment reports r/t unknown impact of current complication on mother and fetus. Disabled Family Coping True Status assessment reports no evidence of inappropriate family coping. Boyfriend accompanies. Risk for r/t High Risk Pregnancy and Financial Concerns. Health Maintenance; Ineffective False Status assessment reports r/t deficient knowledge about high risk pregnancy. Scenario 1 The nurse completes an initial assessment. T 37.4 C, 99.3 F; Heart rate 90, regular; RR 20, regular; BP 142/90 mmHg; FHR 145, moderate variability, 2 accelerations to 160 in 20 minutes, no decelerations. No contractions on electronic fetal monitoring or by palpation. Abdomen soft but tender in right upper quadrant. Urine negative for protein on dipstick. No vaginal bleeding or leaking of fluid. No pedal edema. DTR +3 bilaterally. Repeat blood pressure noted to be 144/90 mmHg. The HCP is notified of the assessment and orders are received. SELECT THE FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE IMPLEMENTED: You correctly ordered 5 out of 5 actions: Your order Correct order Step Explanatio [Show More]

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