Complex Carla Documentation.WELL EXPLAINED WITH VERIFIED ANSSWERS.

Documentation Assignments 1. Document your initial assessment data for Carla Hernandez. Include the following: uterine activity (frequency, duration, and intensity), fetal heart rate activity (baseline fetal heart rate, long-term variability, accelerations, and decelerations), vaginal discharge, vaginal bleeding, and maternal vital signs. Contraction is occurring every 4 minutes and lasting 50 seconds, fetal heart 140’s before breaking water afterwards baby is in distress heart rate 60’s, effaced 100% and dilated 6cm, no fluid on pad underneath mom. 2. Document the medication(s) that you administered. Gave a 500ml bolus of LR for non-assuring fetal heart tones. 3. Document the situation-background-assessment-recommendation (SBAR) communication to Carla Hernandez’s provider. a. S: Pt C.H 32 yr. old female present in active labor with a umbilical cord prolapse on 10/2/20. b. B: No known allergies, G2P1L1 c. A: No headache or visual changes, lungs clear bilateral, heart rhythm normal, skin cool with no edema. d. R: Prepare for C-section, call anesthesia, NICU team, and surgery 4. Using SBAR, document the events surrounding the artificial rupture of membranes by Carla Hernandez’s provider. Note the times for the nursing interventions taken during this simulation and evaluate the effectiveness of these measures in resolving the identified problem(s). a. S: Pt C.H 32 yr. old female present in active labor with a umbilical cord prolapse on 10/2/20. b. B: No known allergies, G2P1L1 c. A: No headache or visual changes, lungs clear bilateral, heart rhythm normal, skin cool with no edema. d. R: Prepare for C-section, call anesthesia, NICU team, and surgery 5. Document the fetal heart rate monitoring and any abnormalities noted during this simulation. Baby was happy and doing well after the water was broken by the provider the baby went into distress. The umbilical cord was prolapsed. The baby experience decrease oxygenation and decrease in heart rate.