Question Situation in Labor and Delivery room 9:30 am Came in a pregnant… Situation in Labor and Delivery room 9:30 am Came in a pregnant client by the name Sally, a 25-year-old nullipara at 40 weeks AOG, accompanied by her husband with complaints of hypogastric pain. Her membranes are intact, and cervix is dilated 3 cm upon initial physical examination (IE). This is a change from 2 cm over the previous 90 minutes. The attending obstetrician ordered the consent for admission, blood test of complete blood count, HbsAG, VDRL-RPR. Her Vital signs as follows: BP 140/90, Temp. 37.2, PR 88, RR 20. FHT ranges from 140-160 beats per minute. Sally claims that she is having frequent (3-2 minutes intervals), strong to palpation contractions that are extremely uncomfortable. She is trembling, complaining of nausea, and begging her nurse for pain relief. The patient’s primary nurse believes epidural anesthesia would be appropriate in assisting the labor pains and comfort of the client and informs the attending obstetrician (OB) about it. The OB attending states he wants the patient to be dilated 4-5 cm before she receives the epidural. The nurse reiterates to the attending OB that her assessment is that the patient is in active labor. Although Sally’s cervix has not demonstrated active labor yet, her nurse believes the pain relief and relaxation resulting from an epidural would be beneficial for the patient. The attending OB agrees to the epidural placement. The patient is fully dilated and begins pushing 3 hours after the placement. 1: 45 pm. She was placed on the delivery table comfortably and was coached the proper pushing technique. After 16 minutes of bearing down, and the creation of right midio-lateral episiotomy to facilitate the labor process, an alive baby boy was spontaneously delivered. Activity: Make a nurse’s note using the SOAPIE format to document nursing care to the client based from the situation presented above. Make a nurse’s notes for a well newborn with Apgar score of 8 -10 obtained 5 minutes after birth. Enumerate the routine newborn care. Health Science Science Nursing NURSING 222 Share QuestionEmailCopy link Comments (0)