Amelia Sung Core Documentation.pdf

Maternity Case 5: Amelia Sung (Core) Documentation Assignments 1. Document Ms. Sung’s admission to the labor unit, including the plan of care and appropriate referrals. ● Sung was admitted 6 hours ago in active labor, she is 39 weeks. On admission she was 4cmdilated, 100% effaced, the fetus is at-1 station and is in vertex position. She is Gravida 2 and with her previous delivery ended with shoulder dystocia which places her at a higher risk or reoccurrence. The NICU has been notified of the potential risk for the fetus and the charge nurse has been notified to assist as needed. 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. ● From the moment the fetus began to crown, Ms. Sung was encouraged to push during contractions. To assist with shoulder dystocia, Ms. Sung was placed in a lateral tilt. After the baby was delivered, the baby was immediately given to the mother to promote bonding with skin to skin contact. 3. Using the situation-background-assessment-recommendation (SBAR) technique, document your communications with the provider when he or she arrives in Ms. Sung’s room after being called. ● Ms. Sung is a 36-year-old filipino female who presented to the clinic in active labor, she is crowning and is ready for delivery. The fetus is presenting in the vertex position and her previous pregnancy ended with a shoulder dystocia, NICU has been notified of the risk. 4. Document the fetal response to the second stage of labor. ● Fetal heart rate is stable at 120 bpm, moderate fetal heart rate variability, and variable decelerations. Fetal descent has been slow. Maternity Case 5: Amelia Sung (Core) This study source was downloaded by from CourseH on :42:06 GMT -05:00 This study resource was shared via CourseH