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    Prenatal Case Scenario

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    Charles Malcolm Dalugdug
    Mrs. Bonifacia Bon-e, a 32-year-old woman, presented for her first prenatal visit with her husband. She had a stillbirth 5 years ago which she blamed herself for. Her current pregnancy was unplanned. On examination, she showed signs of anemia. Her CBC showed low RBC, hemoglobin, and hematocrit levels. The doctor diagnosed her with anemia and prescribed iron supplements as well as prenatal vitamins and vaccines. Her estimated due date was calculated.

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    Prenatal Case Scenario

    Uploaded by

    Charles Malcolm Dalugdug
    53 views4 pages
    Mrs. Bonifacia Bon-e, a 32-year-old woman, presented for her first prenatal visit with her husband. She had a stillbirth 5 years ago which she blamed herself for. Her current pregnancy was unplanned. On examination, she showed signs of anemia. Her CBC showed low RBC, hemoglobin, and hematocrit levels. The doctor diagnosed her with anemia and prescribed iron supplements as well as prenatal vitamins and vaccines. Her estimated due date was calculated.

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    PRENATAL-CASE-SCENARIO

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    Mrs. Bonifacia Bon-e, a 32-year-old woman, presented for her first prenatal visit with her husband. She had a stillbirth 5 years ago which she blamed herself for. Her current pregnancy was unplanned. On examination, she showed signs of anemia. Her CBC showed low RBC, hemoglobin, and hematocrit levels. The doctor diagnosed her with anemia and prescribed iron supplements as well as prenatal vitamins and vaccines. Her estimated due date was calculated.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    53 views4 pages

    Prenatal Case Scenario

    Uploaded by

    Charles Malcolm Dalugdug
    Mrs. Bonifacia Bon-e, a 32-year-old woman, presented for her first prenatal visit with her husband. She had a stillbirth 5 years ago which she blamed herself for. Her current pregnancy was unplanned. On examination, she showed signs of anemia. Her CBC showed low RBC, hemoglobin, and hematocrit levels. The doctor diagnosed her with anemia and prescribed iron supplements as well as prenatal vitamins and vaccines. Her estimated due date was calculated.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    Central Mindanao University

    University Town, Musuan, Maramag


    Bukidnon
    College of Nursing

    Case Scenario on PRENATAL CARE

    Case Scenario: Patient on her first prenatal visit

    MATERNAL HEALTH HISTORY

    Mrs. Bonifacia Bon-e is a 32-year-old multigravid, who came on her first prenatal visit to the
    Gynecologist’s office. Her husband, Bonifacio Bon-e Jr., accompanied her. She told the nurse
    that she had just found out a week earlier that she was pregnant. She took 5 pregnancy tests,
    and all kits turned positive. In the first month after her last menstrual cycle, she also reported
    having nausea and vomiting, but did not suspect as pregnant because she had been anemic and
    experienced nausea even before; and besides she had irregular menstruations.

    The husband conveyed that they have been planning to have a baby since they lost their first
    born on Bonifacia’s 7th month of pregnancy due to stillbirth, 5 years ago.

    According to Bonifacia’s, it was upsetting for both of them since it should have been the first
    grandchild in their family. She was blaming herself at that time because she was thinking she
    was not being careful during her pregnancy and continued to work in their store. Her husband
    said’ “Permi man gud na siya ug alsa-alsa ug bug-at ato nga higayon kay gabaligya lagi mi ug
    mga tanom. Feeling niya certified plantita kaayu sya. Sa tan-aw nako mao gyud to’y hinungdan
    sa pagkahulog sa bata sa iyang tiyan”. Bonifacia then said, “Guol bitaw ko ato ma’am kay
    nabasol jud ko ato sa ako pamilya kay nag tuga-tuga daw ghapun ko ug trabaho.. Wala man
    gud lain masugo.” When asked further details about the stillbirth, Bonifacia said “Naipit man
    daw ang tubo sa pusod ingun sa Doctor, giingnan bitaw nako ako bana, ginabasol gihapun ko”.
    The copy of documentation from the previous pregnancy was handed over to the nurse and it
    revealed that in her ultrasound, no FHT was detected after complaints of no fetal movement felt
    at 8th month. She delivered via NSVD after induction of labor.

    As the nurse was completing the health history for documentation and monitoring, further
    information revealed that her LMP is July 8, 2021; No report of infection and medications taken
    since the time Bonifacia consider she is pregnant. But she noticed that she had nasal congestion
    around the end of July but did not take any medications for that because she just did steam
    inhalation; The only exercise she gets is when she is working at their store and walking around
    from their house to the store; Bonifacia and her husband lives with her mother in-law and her
    cousin. She eats whatever they can afford but she loves eating chips and drinks soft drinks; she
    acknowledged that there were times she forgets to drink water since the only available drink at
    their store is the cola. Approximately she drinks 3-4 glasses of water in a day. She does not have
    any problem with regards to her sleep but sometimes interrupted by her husband’s snoring,
    which seldom happens. She was a smoker and occasionally drinks alcohol since she was 17
    years old but stopped when she had her first pregnancy. Since then she never had a smoke or a
    drink.
    But the husband informed the nurse that he is also a smoker and usually consumes 10 sticks
    /day and occasionally drinks.

    Past Medical History: She revealed that she had her appendix removed when she was 20
    years old and was admitted for 3 days. No other reported diseases except for allergy to shrimps
    and eggs. She was only taking Cetirizine 10mg whenever needed as per her doctor’s order. She
    reported that she was able to complete all of her immunization and she received a dose of
    tetanus toxoid from her previous pregnancy at 5 months. For her Anemia, she has been taking
    Iron supplement since she was diagnosed at 18.

    Gynecological History: At 11 years old, she had her first menstruation. She's been
    menstruating irregularly ever since. She states that every other month, she menstruates.
    Usually, with mild to strong flow, it lasts about 5-7 days. She normally switches her pads 5-6
    times a day and in the first 3 days she is soaked and in the following days she has a mild to
    light flow. In the first 2 days of menstruation, though not all the time, she feels menstrual
    cramps. She only takes 220mg of Aleve while she feels the pain.

    Physical examination reveals:

    Vital Signs:
    BP: 100/70mmhg
    Temp: 36.7 degrees Celsius
    PR: 95 BPM
    RR: 24 BPM
    Weight: 170 lbs
    Height: 5” in
    Blood type: A+
    Fundic height: 17cms
    FHT: 134 BPM via Doppler in Left upper quadrant

    Inspection: Noted Pallor. There are noticeable neck veins and no enlargement is observed.
    From the previous birth, a slight linea nigra and stretch marks are also evident. Breasts are
    asymmetric, there is no dimpling and discoloration observed, nipples and areolas are black in
    color, her breast looks bigger and firmer according to the patient. There is a globular belly.
    Lower extremities have been inspected and no edema has been identified. Palmar erythema
    noted.

    Palpation: Thyroid is non-palpable; breasts are full and tender; fetus outline is recognized;
    ballotting is noted and fetal outline is recognized.

    Pelvic Examination: (+) Goodell’s sign, (+) Chadwick’s sign, (+) Hegar’s sign; patient
    reported increased frequency in urination.
    Laboratory Tests:
    CBC with differential/ Platelet
    Result Interpretation

    WBC 15,000/ul High

    RBC- 4.09/ UL Low

    Hemoglobin 9.0 Low

    Hematocrit 40.7

    MCV 114 high

    MCH 39.1 high

    Platelet 254

    Neutrophils 57

    Lymphs 32

    Monocytes 8

    ABO group and RH type


    ABO Group A

    Rh type RH (D) POSITIVE

    Pregnancy test Positive

    BUN + Creatinine
    BUN 9

    Creatinine, Serum 0.87

    Medication and Vaccines:


    Doctor ordered:

    Vitamin D 400IU OD
    Vitamin C 70 mg OD
    Folic Acid 400 mcg OD
    Fe SO4 60 mg OD
    Tetanus toxoid vaccine 1 dose today; 2 dose to be given 1 month after; 3 dose 2 weeks before
    nd rd

    EDD.
    To schedule for Tdap Vaccine next month during a prenatal visit.

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