Jennifer Lopez is a 25-year-old female patient G1P0 who is currently 39 3/7 weeks gestation. She is admitted to the hospital to be induced for being post-date. She is positive for Group Beta streptococcus and receiving IV antibiotics per protocol. She is 65 inches (162.5 cm). Her pre-pregnancy weight was 115 pounds (52.3 kg). She gained 18 pounds (6.8 kg) during this pregnancy. She just had spontaneous rupture of membranes with a moderate amount of thick meconium fluid at 9 pm. The nurse performed a vaginal check, and her cervix is dilated to 4 cm, 8 percent effaced and -1 station. Pitocin is infusing at 8 mU/minute intravenously.
Jennifer lives with a roommate and is no longer involved with the father of her baby. Her family support is limited to her older brother, Sal. She smokes one pack of cigarettes a day and has not had a job for over a year and states money is tight. She admits to not eating very healthy during the pregnancy because it is easier to grab hamburger and coke than cook. She missed a few of her prenatal visits due to transportation issues and did not attend any prenatal classes. Her sister is present as her support person during labor and delivery.
Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment:
T: 99.9 F/37.7 C (oral) Provoking/Palliative: Uterine contractions
P: 92 (regular) Quality: Severe cramping; moderate to palpation
R: 18 (regular) Region/Radiation: Low pelvis
BP: 128/68 Severity: 6/10
O2 sat: 99 % LA Timing: With uterine contractions
GENERAL APPEARANCE: Calm and appears to be resting between contractions. Using breathing techniques during contractions appropriately
RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort
CARDIAC: Pink, warm & dry, no edema, heart sounds regular with no abnormal beats, pulses strong, brisk cap refill, 1+ bilateral pedal edema
NEURO: Alert and oriented to person, place, time, and situation (x4)
FHT’s: 140s regular
Variability: See monitoring strip to address
Accelerations: See monitoring strip to address
Decelerations: See monitoring strip to address
Frequency: Every 3-4 minutes
Duration: 60-70 seconds
Intensity: Moderate to palpation
Diagnostic Results: Complete Blood Count (CBC)
WBC HGB WBC PLTs % Neuts
Current: 10.2 11.2 240 62
Over the past hour, fetal heart tones (FHT) have remained at 140 with
Minimal variability and no accelerations. She has had three more variable decelerations lasting 30-40 seconds. You position Jennifer on her left side, and she receives an IV bolus of 1000 mL LR and O2 is applied via non-rebreather mask at 10 liters. You are in the room trying to help her breathe through her contractions when she has a prolonged late deceleration lasting three minutes with FHTs in the 70s before returning to 120 bpm.
Consent for C-section
Terbutaline 0.25 mg subcutaneous x1
0.9% NS 1000 mL IV bolus
Foley indwelling catheter
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