your client rina, 35 years old, G1 Po, arrives via wheelchair to the labor and b
ID: 89900 • Letter: Y
Question
your client rina, 35 years old, G1 Po, arrives via wheelchair to the labor and birth init in active labor from the emergencydepartment. Rina is a 41 weeks and 3 days of gestation. she states she is scheduled for induction of labor in 2 days. there is moderate vaginal bleeding on the towel in the chair. Rina states her membranes ruptured about 30 minutes ago and there was not much water, mostly blood. now the baby is not moving much. this is your second day in the labor and birth unit with an Rn mentor. she applies ultratal sound and tocodynamomter for fetal monitoring. you are asked to assist your mentor by taking vital signs. Rina's vital signs are temperature 37 celcius. pulse 98, respirations 22, blood pressure 100/54 aand oxygen saturation of 91%. the fetal heart rate baseline rate is between 170 and 180 per beats per minute, the tracing looks smooth and the fetal heart rate is decreasing after every contraction with return to baseline after the contraction is over. contractions are occuring every 2 minutes. Rina's pain sciore is 8/10. 1) write three nursing disgnosis based on this scenerio 2) write a care plan based on the three diagnosis
Explanation / Answer
The client Rina who is 35 years old , G1PO indicates that the client is pregnant for the first time and has not given
birth.As Rina states there is moderate vaginal bleeding on the towel in the chair, her membranes ruptured about 30 minutes ago and there was not much water, mostly blood and baby is not moving much, all these symptoms indicate she has Premature rupture of membranes(PROM). The care plan should include assessing the client for signs and symptoms of infection, promoting comfort and relaxation and demonstrating proper hand hygiene techniques to the client.
Rina's vital signs of temperature 37 celcius indicates maternal fever due to dehydration, pulse 98 indicates early sign of blood loss, respirations 22 means normal and regular, blood pressure 100/54 means bradycardia indicating uterine hemorrhage and oxygen saturation of 91% indicates hypoxemia. The care plan should include monitoring for uterine contractions and fetal well being. and initiation of IV therapy to maintain hydration.
The fetal heart rate ,baseline rate between 170 and 180 per beats per minute, the trace looking smooth and the fetal heart rate decreasing after every contraction with return to baseline after the contraction is over indicates
fetal tachychardia. Depending on the cause the care plan should include the following- administration of fluid bolus if the underlying cause is dehydration, if cause is maternal fever the care plan should include treatment with antipyretics.
Therefore, based on the above scenario the nursing diagnosis includes premature rupture of membranes (PROM), Maternal fever, uterine hemorrhage and fetal tachycardia.
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