NCM 109

Case
Anal
ysis
Rosada, Analyn Joy
G.
BSN 2-A
NCM 109
CASE ANALYSIS 2.2
Patricia is a 17-year-old gravida 1, para 0 at 34 weeks of gestation, who is visiting her physician
for a routine prenatal visit. When weighing Patricia, the nurse finds that she has gained 6 lbs in
the past 2 weeks.
1. What is the main objective after this initial assessment?
The main objective after the nurse’s initial assessment is to identify why Patricia
had a sudden excessive weight gain. Several studies have found that pregnancy-induced
hypertension (PIH) is most likely a cause or possibly an increased food intake.

2. What is the most important question or problem that must be solved during Patricia’s
prenatal visit?
The most important thing that the attending physician must be solved is to first
find out if Patricia’s weight gain is due to pregnancy-induced hypertension and then
treat it accordingly through creating interventions.

3. What are the nurse’s priority assessments? Why?

The nurse priority assessment is to check for other signs and symptoms of PIH
like increased blood pressure, presence of protein in the urine, edema (particularly of
the face and fingers), epigastric pain, visual changes such as spots or blurring, severe and
unrelenting headache, and dyspnea.

The nurse obtains a clean-catch urine specimen from Patricia and takes her vital signs
(temperature, 37° C [98.6° F]; pulse, 82 bpm; respirations, 20 breaths/min; blood pressure,
146/90 mm Hg); the FHR is 144 to 150 bpm. Deep tendon reflexes are normal (21), and no
clonus is present.

4. What testing would you expect to be performed on the urine specimen? Why?
A dipstick test should be performed to identify proteinuria and to detect
excessive levels of protein in the urine.

5. What information might the nurse need from previous prenatal visits, and why?
The nurse needs the information about Patricia’s past pattern of weight gain and
her previous vital signs to interpret or evaluate the present information more accurately
and precisely.

6. What questions should the nurse ask Patricia while assessing her?
 The nurse should ask Patricia if her rings are tight (finger edema), if she has spots
in front of her eyes, blurred vision, or severe headaches (cerebral edema), if she has
upper abdominal pain or nausea (distended liver capsule), and if she has difficulty
breathing (pulmonary edema).

Patricia’s physician diagnoses mild preeclampsia and will initially manage Patricia at home.
7. What findings would lead the physician to the diagnosis of mild preeclampsia?
Findings like high blood pressure plus high levels of protein in the urine.

8. Why do you think the physician is recommending home management at this time?
I think it is because Patricia’s PIH is just mild, and the fetal signs are good and
favorable. Moreover, delaying the birth of the baby would be favorable since it is 34
weeks unless the PIH worsens. In that case, poor placental perfusion is likely to cause
the fetus more problems, including possible fetal demise, than preterm delivery.

9. What teaching is essential regarding Patricia’s home care? Do you think that it is
important to include a family member in teaching? Discuss reasons for including others
in Patricia’s teaching with one or more classmates and list the group’s reasons here.
Teaching about activity restrictions, including how to attain them, as well as fetal
activity, maternal blood pressure, weight, and urine protein levels. I believe it is
important to include a family member in teaching because in case Patricia is unable to
report to her physician or forget the teachings, her family will be the one to take in
charge. Thus, they must be trained how to report signs and symptoms and when to
return for fetal monitoring studies and regular prenatal appointments.

NCM 109
RLE CASE ANALYSIS 2.3
Ann is admitted at 33 weeks of gestation saying that she thinks her “water broke.” This is her
fourth pregnancy. Two of her infants were preterm, born at 32 and 27 weeks of gestation, and
she has had one elective termination of pregnancy. She has had regular prenatal care in the last
6 weeks of gestation.

1. What are the most important additional assessments that the nurse should make?
The nurse should perform the following additional assessments: attempt to verify
whether Ann's membranes have ruptured without performing a vaginal examination;
determine when they have ruptured; assess maternal vital signs and fetal heart rate,
specifically looking for signs of infection; assess for contractions that may indicate
preterm labor and preterm premature rupture of membranes.

The nurse notes that a small amount of fluid with a strong odor is draining from Ann’s vagina.
Using a speculum examination to obtain fluid, the pH test turns blue-black on contact with the
fluid, and a fern test is positive. Maternal vital signs are as follows: temperature, 37.2° C (99° F);
pulse, 86 bpm; respirations, 22 breaths/min; and blood pressure, 132/80 mm Hg. The fetal heart
rate is 162 to 170 bpm. Ann occasionally has a contraction lasting 20 to 30 seconds.

2. Which data from these assessments are most relevant?

Data that are most relevant are fluid draining from vagina; positive pH (7.5) and fern
tests; fluid with a strong odor; fetal tachycardia; occasional contraction.

3. What is the main judgment that you would make from these data? What is the basis for that
judgment?
Ann's membranes have ruptured, based on vaginal fluid drainage and positive ph and
fern test results. The strong fluid odor and fetal tachycardia indicate infection. Contractions
indicate the possibility of preterm labor.
.
4. Would you perform a vaginal examination at this point? Why or why not?
No. A vaginal examination is not advised at this time because the vaginal discharge is a
characteristic of amniotic fluid indicating that membranes are truly ruptured; there appears to
be an infection, Ann’s gestation is preterm, and she is already having contractions. Furthermore,
an examination might introduce more microorganisms into the uterus and may increase
contraction.
NCM 109
RLE CASE ANALYSIS 2.4
Shawna is an 18-year-old primigravida admitted to the birth center at 27 weeks of gestation in
probable preterm labor. Her membranes are intact. The physician writes the following orders:
• Nothing by mouth (NPO) except ice chips or clear fluids
• Complete blood count
• Catheterized urine for routine analysis and culture and sensitivity
• Intravenous (IV) fluids: Ringer’s lactate at 200 mL/hr for 1 hour, then 125 mL/hr
• Routine fetal monitoring and maternal vital signs

1. What position is appropriate for Shawna? Why?

A side-lying position with the head of the bed low promotes placental blood flow and
decreases pressure on the cervix from the fetal presenting part. Bed rest can help to minimize
uterine activity.

2. What is the purpose for a urinalysis and urine culture and sensitivity testing?
The purpose of urinalysis is to detect and manage wide range of disorders like urinary
tract infection which is associated with preterm labor and reduces the effectiveness of
measures to stop preterm labor. Antibiotics may be ordered after collection of sterile urine for
tests.

Shawna will receive magnesium sulfate for tocolysis.

3. Which nursing observations are essential in relation to magnesium sulfate? Why?

Urine output of at least 30ml per hour, presence of deep tendon reflexes, and
respiratory rate of at least 12 breaths per minute which suggest that the magnesium levels will
also be ordered.

Contractions stop, and Shawna will begin taking oral terbutaline.

4. What nursing observations are essential related to the use of oral terbutaline?
Maintain even spacing if drugs, expect side effects such as palpitations, restlessness,
tremor, weakness, or headaches. Report heart rate greater than 110 bpm, chest pain, or
dyspnea.