Tutorial: Real Life RN Maternal Newborn 4.0
Module: Preeclampsia
Individual Name: Israel Lopez
Institution: West Coast U Ontario BSN
Program Type: BSN
Standard Use Time and Score
Date/Time Time Use Score
Preeclampsia 5/10/2024 4:34:42 PM 5 min Strong
Reasoning Scenario Details
Preeclampsia - Use on 5/10/2024 4:29:19 PM
Reasoning Scenario Performance Related to Outcomes:
*See Score Explanation and Interpretation below for additional details.
Needs
Body Function Strong Satisfactory Improvement
Cardiac Output and Tissue Perfusion 100%
Cognition and Sensation 100%
Excretion 100%
Oxygenation 100%
Reproduction 100%
Needs
NCLEX RN Strong Satisfactory Improvement
RN Management of Care 100%
RN Safety and Infection Control 100%
RN Pharmacological and Parenteral Therapies 100%
RN Reduction of Risk Potential 100%
RN Physiological Adaptation 100%
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Report Created on: 5/10/2024 04:34 PM EDT REP_RSIndv_ModuleReport_1_0
, Needs
QSEN Strong Satisfactory Improvement
Safety 100%
Decision Log:
Scenario Nurse Alex performed a focused assessment and is preparing to transfer Ms.
Kline to the maternal newborn unit.
Question Nurse Alex is reviewing the EMRs in preparation to transfer Ms. Kline to the
maternal newborn unit. Use the SBAR format to prepare a transfer report. (Enter
your response, then click on the submit button at the bottom of the screen.
Compare your response to the one provided.)
Selected Option S: 25 yo female, G1, P0, at 27 weeks gestation came to the ED at 0800. B:
reports n/v, weight gain, blurred vision. A: V/S T 37, BP 162/89, P 92, RR. 22,
O2 stat. 97%, edema on face and hands, tenderness at upper right quadrant. R:
transfer to maternal newborn unit
Rationale SBAR:S = Situation: 25 year-old female, gravida 1 para 0, at 27 weeks
gestation. Came to the ED this morning at 0800.B = Background: Reports
sudden weight gain, and a new onset of nausea & vomiting, also blurred vision
and headache. Says she had breakfast earlier this morning but that she vomited
soon after eating.A = Assessment: Vital Signs: T 37.0, P 92, R 22, BP 162/88,
O2 sat 97%, urine protein 1 +, deep tendon reflexes 3+, reports right upper
quadrant pain, nausea and vomiting and blurred vision with a headache.R =
Recommendation: transfer to maternal newborn unit.
Optimal Decision
Scenario Nurse Morgan completes the admission assessment and selects the appropriate
nursing interventions.
Question Nurse Morgan completes an admission assessment for Ms. Klein. Based on the
assessment, which of the following is the priority nursing intervention at this
time?
Selected Option Initiate seizure precautions.
Rationale The greatest risk to the client and fetus is injury from seizures and resulting
hypoxemia. The priority intervention is to initiate seizure precautions.
Optimal Decision
Scenario Nurse Morgan prepares to call Dr. Hunt and give a report.
Question Nurse Morgan prepares to call Dr. Hunt and give a report. Which of the following
is the most important clinical data for Morgan to include in the SBAR report?
Selected Option Elevated blood pressure
Rationale The elevated blood pressure is the priority clinical finding to include in the SBAR
report. The greatest risk to the client and her fetus is impaired tissue perfusion
to the placenta and vital organs secondary to arteriolar vasospasm.
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Report Created on: 5/10/2024 04:34 PM EDT REP_RSIndv_ModuleReport_1_0