Maternity Case 5: Amelia Sung (Core) Documentation Assignments, Questions With Answers.

1. Document Ms. Sung’s admission to the labor unit, including the plan of care and appropriate referrals. Ms. Sung is a 36 y/o Filipino woman, G2P1 admitted approx. 6 hours ago in active labor. She was 4cm dilated and 100% effaced and station -1. Epidural anesthesia was initiated at 0230. The membrane ruptured at 0330 and the amniotic fluid was clear. Since then she has dilation 6 cm and the fetus is presently at -1 in the vertex position. She is fully dilated and began pushing. The fetal heart rate is within normal limits with moderate deceleration. Fetal began to crown and was given O2 via nonrebreather mask at 10 L and LR running at 125ml/hr. Ms. Sung’s last baby was a shoulder dystocia. 2. Document the essential events related to the time of birth, including the activities and interventions from the time of crowning to the complete expulsion of the fetus. 16:55 Performed at vaginal exam. The head was crowning 05:12 Checked for blood, lochia and fluid on the bed 05:33 Changed and weight the bed pads 05:56 Notified NICU of risk 06:27 Prepared the delivery table 06:44 Prepared the