Maternity Case 5: Fatime Sanogo
Documentation Assignments
1. Document your inital assessment data for Ms. Sanogo, including vital signs, fundal
assessment (consistency, positon, locaton), lochia assessment (amount, color, odor,
consistency), and pain (locaton, quality, severity).
ANSWER:
a. Pulse: Present, Blood pressure: 101/51 mmHg, Respiraton: 18. Conscious state:
Appropriate, SpO2: 97%, Temp: 37 C; 20 breaths per minute – chest moving
equally;
PERRLA and pupils 7mm; heavy red present lochia on pads/bed suggestng
1190 mL of lochia was on the pads; uterus was sof and boggy; pain of 5 out of
10 on 1 to 10 scale located in the abdomen
2. Write the situaton-background-assessment-recommendaton (SBAR) communicatons you
would use to update the provider on Ms. Sanogo’s status afer your frst encounter with her.
ANSWER:
a. S: Ms Sanogo, heavy blood and lochia present suggestng postpartum hemmorage
b. B:14 hours postpartum - delivered 9 lb baby at 0605; had a 2nd degree perineal
laceraton repair afer prolonged labor
c. A: Patent status/VS: Heart rate: 112. Pulse: Present. Blood pressure: 94/49 mmHg.
Respiraton: 21, chest moves equally; Conscious state: Appropriate. SpO2: 95%. Temp:
37
C; heavy bloody lochia present on pads and bed; performed fundal massage; uterus did
not frm up properly; is sof and boggy. Afer changing/weighing the bed pads; increase
in weight of the bed pads suggests that approximately 1190 mL of lochia was on the
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Documentation Assignments
1. Document your inital assessment data for Ms. Sanogo, including vital signs, fundal
assessment (consistency, positon, locaton), lochia assessment (amount, color, odor,
consistency), and pain (locaton, quality, severity).
ANSWER:
a. Pulse: Present, Blood pressure: 101/51 mmHg, Respiraton: 18. Conscious state:
Appropriate, SpO2: 97%, Temp: 37 C; 20 breaths per minute – chest moving
equally;
PERRLA and pupils 7mm; heavy red present lochia on pads/bed suggestng
1190 mL of lochia was on the pads; uterus was sof and boggy; pain of 5 out of
10 on 1 to 10 scale located in the abdomen
2. Write the situaton-background-assessment-recommendaton (SBAR) communicatons you
would use to update the provider on Ms. Sanogo’s status afer your frst encounter with her.
ANSWER:
a. S: Ms Sanogo, heavy blood and lochia present suggestng postpartum hemmorage
b. B:14 hours postpartum - delivered 9 lb baby at 0605; had a 2nd degree perineal
laceraton repair afer prolonged labor
c. A: Patent status/VS: Heart rate: 112. Pulse: Present. Blood pressure: 94/49 mmHg.
Respiraton: 21, chest moves equally; Conscious state: Appropriate. SpO2: 95%. Temp:
37
C; heavy bloody lochia present on pads and bed; performed fundal massage; uterus did
not frm up properly; is sof and boggy. Afer changing/weighing the bed pads; increase
in weight of the bed pads suggests that approximately 1190 mL of lochia was on the
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