Breastfeeding_Newborn_RAPID_Reasoning_1

Postpartum Vaginal Delivery SKINNY Reasoning Suggested Answer Guidelines Anne Jones, 17 years old Primary Concept Reproduction Interrelated Concepts (In order of emphasis) • Clotting • Clinical Judgment • Communication NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Case Study Safe and Effective Care Environment • Management of Care 17-23%  • Safety and Infection Control 9-15% Health Promotion and Maintenance 6-12%  Psychosocial Integrity 6-12%  Physiological Integrity • Basic Care and Comfort 6-12%  • Pharmacological and Parenteral Therapies 12-18%  • Reduction of Risk Potential 9-15%  • Physiological Adaptation 11-17%  Part I: Recognizing RELEVANT Clinical Data History of Present Problem 7:00 am First Day Post-Delivery Night Shift Report: Anne Jones is a 17-year-old G1 P1 39 weeks’ gestation who delivered a healthy male infant at 2032 yesterday. Placenta delivered at 2045. No pain medication was given. She received a 250 mL bolus of Pitocin 30 units/500 mL IV after the delivery of the placenta then received 200 mL/hour until the IV bag was completed. The uterus is firm, one finger breadth below umbilicus and midline — Lochia moderate rubra. Mid-line episiotomy is well approximated, slightly bruised and perineum is slightly swollen. She had an ice pack applied to perineum throughout the night. Anne is up and ambulating ad lib and voiding without difficulty. She had 500 mL in/850 mL urine out. Vital signs: BP: 124/78, P: 74, R: 18, T: 98.6 F/37.0 C, O2: 98% room air, Pain 3/10 in perineum. She is on a regular diet. She was positive for Group Beta strep (GBS) and received a total of three doses of ampicillin IVPB during labor, her blood type is B-, and rubella positive. Infant Report: Infant Apgars were 8 and 9. Weight: 7 lbs. 0 oz. (3.2 kg), 20 inches (50.8 cm) long. Baby has breast fed and latched on for five minutes on both sides three times, and Anne is holding and talking to her baby. She plans on having the baby circumcised. The baby had three wet and meconium diapers. Cord blood was sent. Personal/Social History: Anne has her mother with her and seems to be relaxed but nervous. The father of the baby is not involved. She plans on breastfeeding for “awhile.” Anne still lives at home, and her mother is planning on helping with the new baby and appears supportive. What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Report: Clinical Significance: Uterus firm and one finger breadth below umbilicus and midline Moderate rubra lochia Midline episiotomy with slight bruising and swelling Voiding without difficulty, 500mL in/850 out B- GBS+ Baby has breast fed and latched on for five minutes on both sides three times Anne is holding and talking to her baby. Expected finding. If elevated above the umbilicus and/or deviated to the right, then indicate full bladder and could lead to boggy uterus with increased bleeding. Expected finding. More than 1pad an hour bleeding is heavy, and uterus needs to be massaged. Expected finding. Continue to monitor for any increasing swelling or bruising that could indicate hematoma. Expected finding. Increased urine output is related to increased blood volume and since the need for blood volume is decreased then the body gets rid of the extra via the kidneys. Continue to monitor. Will need to follow up and find out baby’s blood type. If the baby is Rh positive, Anne will need Rhogam within 72 hours. Received ampicillin during labor but still need to monitor baby for signs of infection that include grunting, retracting, nasal flaring, poor feeding, listlessness, hypoglycemia, hypothermia. Baby has fed an adequate amount as a newborn. Interaction with the baby indicates that appropriate bonding and The baby had three wet and meconium diapers. attachment is taking place. This is expected and adequate amount of output for newborn RELEVANT Data from Social History: Clinical Significance: Teen G1P1 Mother is planning on helping with the new baby and appears supportive. First baby and young. Will need lots of education and support even though her mother is helpful Father of the baby not involved but her mother is supportive Patient Care Begins: You complete your first assessment: Current VS: P-Q-R-S-T Pain Assessment: T: 98.6 F/37.0 C (oral) Provoking/Palliative: Breastfeeding P: 76 (regular) Quality: Cramping and tenderness of perineum R: 18 (regular) Region/Radiation: Uterus and perineum BP: 125/80 Severity: 4/10 O2 sat: 98% room air Timing: When breastfeeding and continuous for perineum What VS data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT VS Data: Clinical Significance: T: 98.6 F/37.0 C (oral) P: 76 (regular) R: 18 (regular) BP: 125/80 O2 sat: 98% room air Pain increased from night shift report VS stable. No clinical red flags present. Breastfeeding stimulates oxytocin production, which causes uterine cramping. This helps decrease risk for hemorrhage but increases pain level. She also has perineum pain which is typical but will need to be assessed further. Watch for S/S of a hematoma (intense pain that is not relieved by pain medication increased bruising and swelling that is painful to touch). Current Assessment: Mom GENERAL APPEARANCE: Calm and quiet appears tired. Baby in a crib next to the bed. RESP: Breath sounds clear with equal aeration bilaterally ant/post, nonlabored respiratory effort CARDIAC: Pink, warm & dry, heart sounds regular with no abnormal beats, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill, 1+ edema in lower extremities bilaterally NEURO: Alert and oriented to person, place, time, and situation (x4) BUBBLE3 BREAST: Lactating; soft, non-tender with evidence of colostrum UTERUS: Fundus boggy 1 cm above umbilicus and deviated to the right BLADDER: Voiding without difficulty. Denies any burning with urination. Hasn’t voided yet this morning. BOWELS: Abdomen soft/non-distended, bowel sounds audible per auscultation in all four quadrants, positive flatus, no BM since delivery. LOCHIA: States hasn’t changed pad this morning, peri-pad saturated with rubra lochia, small clots noted. EPISIOTOMY: Perineum slightly bruised and swollen, small hemorrhoids noted. EXTREMITIES: Calves cool to touch, no tenderness bilaterally EMOTIONAL: Quiet appears fatigued, currently interacting with baby What assessment data are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential/Health Promotion and Maintenance) RELEVANT Assessment Data: Clinical Significance: All other assessment data WNL Fundus boggy 1 cm above umbilicus and deviated to the right Increases risk for hemorrhage and could indicate clots in the uterus or retained placental pieces. It could also be related to the fact that she hasn’t voided this morning.