Description
mod 4 cs 3 respond to questions concerning appropriate nursing care of the client presented
J.F. is an 18-year-old woman, gravida 1 para 0, at 38 weeks’ gestation. She felt fine until 2 days ago, when she noticed swelling in her hands, feet, and face. She states she has a frontal headache, which started yesterday and has not been relieved by acetaminophen or coffee. She says she feels irritable and does not want the “overhead lights on.” Her physician is admitting her for induction of labor. You begin to assess her.
Chart View Assessment
Vital signs: BP 152/84 mm Hg; HR 88 beats/min
Oral temperature: 98.8° F (37.1° C)
Weight: 186 lb (84.4 kg); height: 5 ft, 4 in (163 cm)
Edema: Noted in hands, feet, and face
Deep tendon reflexes (DTRs) +2, no clonus
Urine dipstick reveals proteinuria +3
1. Based on J.F.’s assessment data, what do you think the possible cause is at this time?
2. As you assess J.F. for edema in her ankles, you note that she is closest to letter B in the figure below, with edema at about 4 mm. How would you document this edema? You note that her level of Edema is 4mm describe the technique used to arrive at this assessment?
3. Describe the grading system for DTR.
4. You check her medical record and note that she has gained 8 pounds (3.6 kg) since her last visit, 1 week ago. What other assessment questions should you ask her at this time?
5. What information should you obtain from her obstetric record?
6. What laboratory values should be considered at this time?
7. Name at least 3 possible maternal and 3 possible fetal complications with J.F.’s potential diagnosis.
8. What risk factors does J.F. have that cause her to be at risk for this condition?
9. Base on your nursing assessment, identify eight nursing interventions that you would implement to help J.F with her signs and symptoms.
CASE STUDY PROGRESS
The physician orders a magnesium sulfate infusion. You prepare the infusion and explain to J.F. what you are doing.
10. J.F. asks you, “Why am I getting magnesium now?” Explain your answer.
11. As you monitor J.F., you observe for signs of magnesium sulfate toxicity. What are potential signs of magnesium sulfate toxicity?
12. Is there an antidote for magnesium sulfate?
CASE STUDY PROGRESS
An oxytocin infusion has been ordered by the physician and is being given intravenously in increments to achieve an adequate contraction pattern. You notice on the fetal monitor strip that J.F. is experiencing seven uterine contractions in a 10-minute period over a 30-minute window, with late decelerations noted on the fetal monitor.
13. Explain what is happening at this time.
14. What are your priority interventions?
15. After your prompt intervention, J.F.’s tachysystole resolves. Write an example of a documentation entry describing this event.
CASE STUDY PROGRESS
J.F. progresses in labor, and at 4-cm dilation her membranes spontaneously rupture. The small amount of amniotic fluid is green.
16. What does the green amniotic fluid indicate? What are the risks?
CASE STUDY PROGRESS
Four hours later, J.F. delivers a 6-pound, 8-ounce boy (2948 grams), with Apgar scores of 6 and 7.
17. What are your responsibilities at this time?
CASE STUDY OUTCOME
J.F. is hospitalized for 5 days. By the time of discharge, her BP was within normal limits and her edema had subsided. Her baby boy experienced no problems.