Chamberlain College Of Nursing Nr 327 Antepartum/Intrapartum Isbar
Fetal heart rate pattern: reassuring non-reassuring Contraction pattern: Deferred; Unspecified; Labor progress: Induction @ 38 weeks with 1 cm dilation, 50% effacement; Maternal physical assessment: Respiratory: WNL; Cardiovascular: WNL denies edema of extremities; Gastrointestinal: bowel sounds active x 4 quadrants, reports occasional nausea; Urinary: denies alterations in urination, urine clear, straw-color; Genitalia: WNL; Musculoskeletal: WNL; Neurological: DTRs + 2; Endocrine: Non-contributory; Immunizations up to date and include: Rubella (titer) immune, Varicella, Tetanus, Pertussis, Hepatitis B, Influenza, and Pneumococcal. IV: Non-Contributory; Unspecified Current meds: Prenatal vitamins, Regular Insulin Labs: Abnormal glucose levels discussed above; Negative proteinuria; Other labs unspecified; Activity: Active, states use of walking for exercise (1 x weekly) R Discharge planning needs: Postpartum care; monitoring for signs of hypoglycemia and hyperglycemia in baby; breastfeeding education; dietary consult and education;
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