Maternity Case 2: Brenda Patton
Documentation Assignments
1. Document your initial assessment data of Ms. Patton, including uterine activity (frequency and
duration), fetal heart rate (FHR) activity (baseline FHR, long-term variability, accelerations, and
decelerations), vaginal discharge, and maternal vital signs.
Maternal Vital Signs
o Heart Rate – 92 beats per minute
o Blood Pressure – 118/72
o Respiratory Rate – 21 breaths per minute
o SpO2 – 98% on room air
o Temperature – 98.6°F
o Pain – 2 on numeric pain scale
Uterine Activity
o Regular contrations with moderate pain intensity
o Contraction 4-5 minutes apart, last 50 seconds
Vaginal Discarge
o Clear
o 300mL amniotic fluid on chuck
Chuck was replaced with a new one.
Fetal Heart Rate (FHR)
o FHR Baseline 141
Occasional accerlation
2. Document the medication(s) that you administered.
Medications Administered
o Penicillin 5,000,000 IU, IV piggyback
o Piggyback infusion of Promethazine IV 12.5mg
3. Document Ms. Patton’s pain during labor (severity during contractions, location, quality, interventions
taken, and response to interventions) and the measures that were taken to promote her desire for a
natural birth.
Pain During Labor
o Ms. Patton claims her pain is a 2 on the numeric pain scale between contractions
and states they are not too bad.
o The pain is located everywhere
o Ms. Patton says that she does not wish to receive any pain medication as she would
like to have a natural delivery.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
Documentation Assignments
1. Document your initial assessment data of Ms. Patton, including uterine activity (frequency and
duration), fetal heart rate (FHR) activity (baseline FHR, long-term variability, accelerations, and
decelerations), vaginal discharge, and maternal vital signs.
Maternal Vital Signs
o Heart Rate – 92 beats per minute
o Blood Pressure – 118/72
o Respiratory Rate – 21 breaths per minute
o SpO2 – 98% on room air
o Temperature – 98.6°F
o Pain – 2 on numeric pain scale
Uterine Activity
o Regular contrations with moderate pain intensity
o Contraction 4-5 minutes apart, last 50 seconds
Vaginal Discarge
o Clear
o 300mL amniotic fluid on chuck
Chuck was replaced with a new one.
Fetal Heart Rate (FHR)
o FHR Baseline 141
Occasional accerlation
2. Document the medication(s) that you administered.
Medications Administered
o Penicillin 5,000,000 IU, IV piggyback
o Piggyback infusion of Promethazine IV 12.5mg
3. Document Ms. Patton’s pain during labor (severity during contractions, location, quality, interventions
taken, and response to interventions) and the measures that were taken to promote her desire for a
natural birth.
Pain During Labor
o Ms. Patton claims her pain is a 2 on the numeric pain scale between contractions
and states they are not too bad.
o The pain is located everywhere
o Ms. Patton says that she does not wish to receive any pain medication as she would
like to have a natural delivery.
From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
