OBVsim2 - Documentation Assignment

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. • Palpated uterus for contractions. Uterus tone soft between contractions. Contractions approximately 4 minutes apart & lasting 50 seconds • FHR 149 @ baseline with occasional acceleration & one episode of early deceleration • No vaginal discharge noted • VS: HR 91, Pulse present, BP 117/71, R 20, O2 97%, Temp 37C. Conscious state appropriate. 2. Document the medication(s) that you administered. • Piggyback infusion of 5million IU of penicillin IV given @ 1036. Pt identified, 5 rights of administration followed. Patient education given. 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. • Patient reports pain rated “about a 2 between contractions” • Patient denies wanting anything for pain. Promoted therapeutic techniques • Patient did not provide a number for pain during contractions, but showing signs via grimacing & moaning 4. Document your handoff report in the situation-background-assessment-recommendation (SBAR) format to communicate what further care Ms. Patton needs. • This is Brenda Patton. She is 18 years old. G1P0 and is 38 weeks & 2 days. She was admitted today and reports that her water broke this morning. Amnisure was positive upon admission. • She is GBS positive. Last vaginal exam revealed 50% effacement & 4cm dilation with fetus at -2 station. She has 5million IU of penicillin IV running in her L forearm. The IV site was flushable and had no redness, swelling, infiltration, bleeding, or drainage upon assessment. Dressing CDI. • Last set of Vitals were: HR 90, Pulse present, BP 121/72, R 19, O2 98%, Temp 37C, conscious state is appropriate • Fetal HR has been between 133 & 149 via EFM. Typically at baseline with occasional acceleration