MaternityCase2_BP Maternity Case 2: Brenda Patton Documentation Assignments

MaternityCase2_BP 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. Brenda Patton is an 18-year-old Caucasian female, G1P0 at 38 2/7 weeks of gestation admitted to the labor and birthing unit for labor assessment. The patient states that her water may have broken earlier this morning and she thinks she is in labor. AmniSure was positive. Vaginal exam reveals 50% effacement of cervix, cervical dilation 4 cm, and fetus at -2 station. The lab report indicates that the patient's group B strep vaginorectal culture taken at 36 weeks was positive. Patient status - Heart rate: 89. Pulse: Present. Blood pressure: 120/71 mmHg. Respiration: 20. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. EFM: Baseline with occasional accelerations. Fetal heart rate: 141. 2. Document the medication(s) that you administered. Penicillin 5 million IU IVPB 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. Uterus tone was soft between contractions. Regular contractions with moderate intensity had started. Contractions were approximately 4 minutes apart and lasting 50 seconds. Pain: 2 between contractions., Location: everywhere 4. Document your handoff report in the situation-background-assessment-recommendation (SBAR) format to communicate what further care Ms. Patton needs. S: ………………………………….CONTINUED………………………………………….