Question Clinical Scenario #3 Progression : Mikaylais a 27-year-old, G2 P1… Clinical Scenario #3 Progression: Mikayla is a 27-year-old, G2 P1 at 38 weeks gestation who was admitted for an induction of labor (IOL) for oligohydramnios. She received dinoprostone 10 mg vaginally X 12 hrs. and then was induced with oxytocin. She had a vaginal delivery, an 8 lb boy, over an intact perineum after 20 hours of labor. She is currently receiving oxytocin IV at 40 mu/min. She has been clinically stable and is about to be transferred to the postpartum unit after a two hour recovery period. She has gotten up to void once and had 50 mL of blood-tinged urine. Her fundus is firm at the umbilicus and hs a small amount of dark red lochia. She is physically exhausted and has been anxious since delivery because her labor and delivery were harder than she ever expected. Last documented VS – T: (oral) 99.2o BP: 110/67 P: 95 bpm R: 18 O2 sat: 98% Last documented Assessment:GEN’L APPEARANCE:Resting in bed, appears uncomfortable, restlessRESP:Breath sounds clear bilaterally, non-labored respiratory effortCARDIAC:Pink, warm & dry, heart sounds regular with no abnormal beats, pulses palpable.NEURO:Alert and oriented X 4 BUBBLE-HEBREAST: UTERUS: BLADDER: BOWELS: LOCHIA: HOMANS: EPISIOTOMY: Lactating; soft, non-tender with evidence of colostrum Right of umbilicus, slightly boggy. 2 fingerbreadths above umbilicusVoided 50 ml after delivery, bladder distended Abdomen soft/nontender, bowel sounds audible per auscultation in all 4 quadrants Rubra. Soaked entire peri pad with 10-12″ diameter puddle of blood weight= 450 mL Negative Perineum intact Noticing:What assessment data is relevant and must be recognized as clinically significant by the nurse?RELEVANT Assessment Data:Clinical Significance:GENERAL APPEARANCE: Appears uncomfortable, restless CARDIAC: Pink, warm/dry, no edema, heart sounds regular with no abnormal beats, equal with palpation at radial/pedal/post-tibial landmarks UTERUS: Right of umbilicus, slightly boggy, palpable bladder BLADDER: Voided 50 ml after delivery, bladder distended LOCHIA: Rubra. Soaked entire peri pad with 10-12″ diameter puddle What is the primary problem that your patient is most likely presenting with? Interpreting: What is the underlying cause/pathophysiology of this primary problem? Responding Which Orders Do You Implement First and Why? Care Provider Orders:Order of Priority:Rationale: Health Science Science Nursing NUR 2005 Share QuestionEmailCopy link Comments (0)