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    Ivan Villapando
    The patient, a 26-year-old woman at 41 weeks gestation, came in experiencing contractions and discomfort. She had a history of gestational diabetes. The nursing assessment identified the patient was at risk for maternal and neonatal injury related to prolonged labor from shoulder dystocia. The plan was to monitor the patient closely and assist with delivery within 15-30 minutes to prevent complications. Interventions would include supporting delivery, assessing for vaginal lacerations, and assisting the patient to push effectively. The goal was to deliver the baby safely without further issues, as evaluated by normal vital signs and APGAR scores.

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    Untitled

    Uploaded by

    Ivan Villapando
    26 views1 page
    The patient, a 26-year-old woman at 41 weeks gestation, came in experiencing contractions and discomfort. She had a history of gestational diabetes. The nursing assessment identified the patient was at risk for maternal and neonatal injury related to prolonged labor from shoulder dystocia. The plan was to monitor the patient closely and assist with delivery within 15-30 minutes to prevent complications. Interventions would include supporting delivery, assessing for vaginal lacerations, and assisting the patient to push effectively. The goal was to deliver the baby safely without further issues, as evaluated by normal vital signs and APGAR scores.

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    The patient, a 26-year-old woman at 41 weeks gestation, came in experiencing contractions and discomfort. She had a history of gestational diabetes. The nursing assessment identified the patient was at risk for maternal and neonatal injury related to prolonged labor from shoulder dystocia. The plan was to monitor the patient closely and assist with delivery within 15-30 minutes to prevent complications. Interventions would include supporting delivery, assessing for vaginal lacerations, and assisting the patient to push effectively. The goal was to deliver the baby safely without further issues, as evaluated by normal vital signs and APGAR scores.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    26 views1 page

    Untitled

    Uploaded by

    Ivan Villapando
    The patient, a 26-year-old woman at 41 weeks gestation, came in experiencing contractions and discomfort. She had a history of gestational diabetes. The nursing assessment identified the patient was at risk for maternal and neonatal injury related to prolonged labor from shoulder dystocia. The plan was to monitor the patient closely and assist with delivery within 15-30 minutes to prevent complications. Interventions would include supporting delivery, assessing for vaginal lacerations, and assisting the patient to push effectively. The goal was to deliver the baby safely without further issues, as evaluated by normal vital signs and APGAR scores.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 1

    Assessment Nursing diagnosis Planning Nursing Rationale Evaluation

    intervention
    Patient A.M. came in having Risk for maternal and By 15- 30 minutes of Monitor for the Comparison of vital signs After performing the
    contractions and feeling neonatal injury related Maternal Care the VS., and before and during intervention during
    uncomfortable. to delay in the delivery patient will be able to: pateint’s level delivery provides a delivery of the baby:
    Objective: 1. The mother of more complete picture The goal is met:
    1. 26 years old of the shoulder and deliver the consciousness of the mother health If the mother delivered
    2. Gravida 3, Parity 2 vaginal laceration as neonate using AVPU. status and possible the neonate safely and
    3. 41 weeks of gestation evidenced by turtle sign normally signs of abnormalities. there is no further sign
    4. Obstretical h/o: Dx to causing prolonged labor without 2. Assess the Using AVPU Scale can of complication.
    have gestational diabetes further patient risk for help determine the If the APGAR score of
    mellitus at 28 weeks age of complication. vaginal urgency of surgical the baby is 7-10 which
    gestation. laceration and treatment and means that the
    2. Maternal patients bladder increased risk for newborn is in good
    1st I.E. result: take part in damage. maternal injury. health
    a. cervix: 3 cm dilated interventions to 2. Shoulder dystocia may The goal is not met:
    b. fundic height: 40 cm maintain their safety 3. Ask for cause the patient to If the intervention that
    6. pelvic ultrasound: normal and in steps to reduce assistance. have vaginal bleeding is provided didn’t help
    admitted for monitoring of risk factors that have Ensure that due to unnatural in the delivery of the
    labor and delivery been identified. there is enough position of the baby baby.
    members of the during delivery If a further complication
    2nd I.E. 4h after, 3. The patient team to 3. Shoulder dystocia is develop after prolong
    spontaneous rapture of maintain safety and support the medical emergency, labor.
    membranes participate in measures delivery of the therefore, more If the APGAR score is
    Cervix: 3cm dilated that protect self baby. intensive monitoring below the normal which
    Administered oxytocin during the treatment. and assistance will be implies that further
    Infusion All through out of the 4. Assist the needed. Asking for an intervention is needed
    labor and delivery, the mother to extra hand is usually the
    3rd I.E. after 4h, baby will be able to: assume the health care worker’s
    Cervix: 7cm dilated McRoberts first move.
    4th I.E. after 4h, 1. The baby maneuver. 4. It promotes the rotation
    Cervix: 10 cm dilated(full) maintain of
    Transferred to delivery efficient tissue 5. Place pressure in the pelvis to let the
    room perfusion and the suprapubic baby pass through
    will be area of the easily.
    delivered mother. 5. To encourage the baby’s
    successfully shoulder to change and
    without rotate
    further
    complication

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