MATERNITY 2 1
Carla Hernandez is a 32-year-old Hispanic female, G2P1 (L1) at 39 5/7 weeks of gestation. She was admitted to labor and delivery in active labor at 0600 hours today, accompanied by her husband Earl. Her contractions began at 0015 hours, and they have been every 3-5 minutes, lasting 60 seconds, since 0330 hours. Baseline FHR has been steady at 140 bpm with no periodic changes noted. Patient denies any leakage of fluid or vaginal bleeding. Last estimated fetal weight was 2,700 g (6 lb) by ultrasound. Patient states that the baby feels smaller than her first. Her first delivery was an uncomplicated vaginal birth, a male born at 40 2/7 weeks of gestation who weighed 2,785 g (6 lb 2 oz).
An hour ago Carla was 5 cm dilated, 90% effaced, and at a 0 station. Membranes are still intact. She has signed all the admission papers. Lactated Ringer’s is running IV at 125 mL/hr in her left arm.
· 1. Document your initial assessment data for Carla Hernandez. Include the following: uterine activity (frequency, duration, and intensity), fetal heart rate activity (baseline fetal heart rate, long-term variability, accelerations, and decelerations), vaginal discharge, vaginal bleeding, and maternal vital signs.
· 2. Document the medication(s) that you administered.
· 3. Document the situation-background-assessment-recommendation (SBAR) communication to Carla Hernandez’s provider.
· 4. Using SBAR, document the events surrounding the artificial rupture of membranes by Carla Hernandez’s provider. Note the times for the nursing interventions taken during this simulation and evaluate the effectiveness of these measures in resolving the identified problem(s).
· 5. Document the fetal heart rate monitoring and any abnormalities noted during this simulation.