Plan II+ NCLEX
Questions
, Student Name: Fariyal Chowdhury _ Date:_4.17.2020
Instructor: Professor Michels _ Group 4 VSIM : Brenda Patton
SBAR of Patient Condition
Situation:
My name is Fariyal. Patient Brenda Patton is G1P0 at 38 2/7 weeks of gestation admitted to the labor and birthing unit for labor assessment.
She is positive for Group B vaginorectal culture and is experiencing contractions. Vaginal exam reveals 50% effacement of cervix, cervical
dilation 4 cm, and fetus at -2 station.
Background:
Brenda Patton is an 18-year-old Caucasian female, G1P0 at 38 2/7 weeks of gestation admitted to the labor and birthing unit for labor
assessment. The patient states that her water may have broken earlier this morning and she thinks she is in labor. AmniSure was positive. The
patient's boyfriend is present, and she has phoned her mother to inform her of her admission. The provider has been notified, and prenatal
records have been pulled. The lab report indicates that the patient's group B strep vaginorectal culture taken at 36 weeks was positive. The
patient wishes to have a natural birth without medication. Admission intrapartum orders have been initiated, initial labs have been drawn,
and a saline lock has been placed in her forearm.
Assessment:
Her current vital signs are: HR: 88 BPM. Pulse: present. BP: 117/70 mmHg. RR: 20. LOC: appropriate. SPO2: 97%. Temp: 37C. Uterus was soft
between contractions. Contractions were regular with moderate intensity with each contraction being 4-5 minutes apart, approximately 50
seconds each. 300 mL of clear, amniotic fluid was noted on the pad where the membrane had ruptured. The fetal baseline heart rate is 149 which
showed periods of episodic acceleration.
Recommendations:
I recommend that vital signs be taken every 30 minutes due to rupture of membrane. Continue to monitor fetal heart rate for possible signs of
fetal distress due to GBS. Provide supportive care. Take note of any signs of maternal or fetal distress.