Review: Client Information Card LABORING Client Name:

Review: Client Information Card LABORING Client Name: Susan Gold Age: 32 Weight: 76Kg Physician: Dr. Richard Smith Client Information: Susan Gold is a 32-year-old gravida 1, para 0, brought up to Labor and Delivery by emergency department personnel in a wheel chair, with chief complaint of “Labor”. Assessment on admission revealed contractions every 5-7 minutes, mild intensity, and lasting 30-40 seconds, with soft cervix, 4 cm’s dilated, 50% effaced, and -1 station, pain level is “5” on scale of 0-10, VS: 98.6, P: 88; R: 22; BP: 130/75, FHR: 120 with variability. Past Medical History: Healthy Social History: Married for 10 years. She works construction outdoors with resultant tanned weathered skin. She smokes 2 packs of cigarettes per day. Prior Medical History: Contractions started at 10:30pm last night and getting closer together with pain increasing. Surgeries/Procedures: Adenoids and Tonsils removed at age 2. Medications: None Review: Client Information Card POSTPARTUM Susan Gold, age 32, Gr 1, Para 1, delivered a male, vaginally, at 7:00 am 1/15/2020. Breast feeding, VS T 99, P 55, R 20, BP 110/72, pain level 0. Not wearing bra. Fundus firm, moderate amount lochia, Foley catheter in place. Diagnostics & Labs: Hgb: 12grams/dl Hct: 36% Blood Type & Rh: A negative; VDRL neg; Rubella non-immune, GBS negative. Review: Client Information Card NEWBORN Client Name: Baby boy Gold DOB: 1/29/21 Weight: 7lbs/ 3181grams Apgar: 8 at 1 min/ 9 at 5 min Breast feeding Physician: Dr. Lassister Client Information: Boy Gold was born at 7:00 am 1/29/2021 Mom: gravida 1, para 0; RH neg; VDRL neg; Rubella non-immune, Gram Beta Strep negative (GBS) VS: 98.6, Apical pulse: 130; R: 36 Medications: Vitamin K 1mg. administered 1/29/18 at 1030; Erythromycin Ophthalmic Ointment administered 1/29/18 at 1025 Circumcision orders: Administer Sucrose 15 ml, PO, immediately prior to circumcision. Administer Tylenol 50mg. Elixir, PO immediately following circumcision Apply Bacitracin Ointment to circumcision site Allergies: None Student Equipment: Uniform, Stethoscope, pen light, watch with second hand, no cell phone. Potential Skills for Scenario: Look at the Client Information card and study any skills that are indicated or relate to anything that may occur in the scenario as related to the information given on the client information card. Look up all medications and know them as a nurse that will be administering them. Refer to ATI Skills Module 3.0 Maternal Newborn & Course Point. Directions: Answer these questions to help prepare for your clinical simulation. 1. How does the client’s past medical history factor into her labor and delivery care, postpartum care, and newborn care? What client teaching needs to be addressed? 2. Explain how to assess contractions and implement non-pharmacological pain management in a laboring mom. 3. What type of a non-complicated fetal heart monitor strip is expected? 4. What position does the laboring client need to be in for Foley catheter insertion? 5. The client has Ibuprofen ordered. What complications may the client experience from this medication? 6. How do you plan to prioritize your care for the laboring client, postpartum client, and newborn? 7. How would the client’s CBC affect care of laboring client, postpartum client, and newborn? 8. Explain how to assess a postpartum and newborn client. 9. What is your priority for laboring client, postpartum care, and newborn care? 10. What client education is needed for the laboring client, postpartum care, and newborn care? SCIENCE HEALTH SCIENCE NURSING NUR 328

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