lOMoAR cPSD| 56342273
Postpartum Vaginal Delivery
UNFOLDING Reasoning
Anne Jones, 17 years old
Primary Concept
Reproduction
Interrelated Concepts (In order of emphasis)
• Clotting
• Clinical Judgment
• Communication
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
• Management of Care 17-23%
• Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity
• Basic Care and Comfort 6-12%
• Pharmacological and Parenteral Therapies 12-18%
, lOMoAR cPSD| 56342273
• Reduction of Risk Potential 9-15%
• Physiological Adaptation 11-17%
History of Present Problem
7:00 am First Day Post-Delivery Night Shift Report:
Anne Jones is a 17-year-old G1 P1 39 weeks’ gestation who delivered a healthy male infant at 2032 yesterday. Placenta
delivered at 2045. No pain medication was given. She received a 250 mL bolus of Pitocin 30 units/500 mL IV after the
delivery of the placenta then received 200 mL/hour until the IV bag was completed.
The uterus is firm, one finger breadth below umbilicus and midline — Lochia moderate rubra. Mid-line episiotomy is
well approximated, slightly bruised and perineum is slightly swollen. She had an ice pack applied to perineum
throughout the night. Anne is up and ambulating ad lib and voiding without difficulty. She had 500 mL in/850 mL urine
out. Vital signs: BP: 124/78, P: 74, R: 18, T: 98.6 F/37.0 C, O2: 98% room air, Pain 3/10 in perineum. She is on a regular
diet. She was positive for Group Beta strep (GBS) and received a total of three doses of ampicillin IVPB during labor, her
blood type is B-, and rubella positive.
Infant Report:
Infant Apgars were 8 and 9. Weight: 7 lbs. 0 oz. (3.2 kg), 20 inches (50.8 cm) long. Baby has breast fed and latched on
for five minutes on both sides three times, and Anne is holding and talking to her baby. She plans on having the baby
circumcised. The baby had three wet and meconium diapers. Cord blood was sent.
Personal/Social History:
Anne has her mother with her and seems to be relaxed but nervous. The father of the baby is not involved. She plans on
breastfeeding for “awhile.” Anne still lives at home, and her mother is planning on helping with the new baby and
appears supportive.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Report: Clinical Significance:
blood pressure 124/78 pain slightly elevated possibly due to recent dleivery and pain
3/10 positive for GBS B- and this and the blood pressure just need to be monitored
rubella normal vaginal delivery
reported
this poses a risk to the infant. she did receive ampicillin
during labor
RELEVANT Data from Social History: Clinical Significance:
mother plans on helping with the new the client seems to be doing well and interacting with the
baby and Ann still lives at home. baby, she has a support system in place that is her mother
plans on breast feeding for an which is good due to her young age
undetermined amount of time
Patient Care Begins: You complete your first assessment:
Current VS: P-Q-R-S-T Pain Assessment:
T: 98.6 F/37.0 C (oral) Provoking/Palliative: Breastfeeding
P: 76 (regular) Quality: Cramping and tenderness of perineum
R: 18 (regular) Region/Radiation: Uterus and perineum
BP: 125/80 Severity: 4/10
O2 sat: 98% room air Timing: When breastfeeding and continuous for perineum
Postpartum Vaginal Delivery
UNFOLDING Reasoning
Anne Jones, 17 years old
Primary Concept
Reproduction
Interrelated Concepts (In order of emphasis)
• Clotting
• Clinical Judgment
• Communication
NCLEX Client Need Categories Percentage of Items from Each Covered in
Category/Subcategory Case Study
Safe and Effective Care Environment
• Management of Care 17-23%
• Safety and Infection Control 9-15%
Health Promotion and Maintenance 6-12%
Psychosocial Integrity 6-12%
Physiological Integrity
• Basic Care and Comfort 6-12%
• Pharmacological and Parenteral Therapies 12-18%
, lOMoAR cPSD| 56342273
• Reduction of Risk Potential 9-15%
• Physiological Adaptation 11-17%
History of Present Problem
7:00 am First Day Post-Delivery Night Shift Report:
Anne Jones is a 17-year-old G1 P1 39 weeks’ gestation who delivered a healthy male infant at 2032 yesterday. Placenta
delivered at 2045. No pain medication was given. She received a 250 mL bolus of Pitocin 30 units/500 mL IV after the
delivery of the placenta then received 200 mL/hour until the IV bag was completed.
The uterus is firm, one finger breadth below umbilicus and midline — Lochia moderate rubra. Mid-line episiotomy is
well approximated, slightly bruised and perineum is slightly swollen. She had an ice pack applied to perineum
throughout the night. Anne is up and ambulating ad lib and voiding without difficulty. She had 500 mL in/850 mL urine
out. Vital signs: BP: 124/78, P: 74, R: 18, T: 98.6 F/37.0 C, O2: 98% room air, Pain 3/10 in perineum. She is on a regular
diet. She was positive for Group Beta strep (GBS) and received a total of three doses of ampicillin IVPB during labor, her
blood type is B-, and rubella positive.
Infant Report:
Infant Apgars were 8 and 9. Weight: 7 lbs. 0 oz. (3.2 kg), 20 inches (50.8 cm) long. Baby has breast fed and latched on
for five minutes on both sides three times, and Anne is holding and talking to her baby. She plans on having the baby
circumcised. The baby had three wet and meconium diapers. Cord blood was sent.
Personal/Social History:
Anne has her mother with her and seems to be relaxed but nervous. The father of the baby is not involved. She plans on
breastfeeding for “awhile.” Anne still lives at home, and her mother is planning on helping with the new baby and
appears supportive.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Report: Clinical Significance:
blood pressure 124/78 pain slightly elevated possibly due to recent dleivery and pain
3/10 positive for GBS B- and this and the blood pressure just need to be monitored
rubella normal vaginal delivery
reported
this poses a risk to the infant. she did receive ampicillin
during labor
RELEVANT Data from Social History: Clinical Significance:
mother plans on helping with the new the client seems to be doing well and interacting with the
baby and Ann still lives at home. baby, she has a support system in place that is her mother
plans on breast feeding for an which is good due to her young age
undetermined amount of time
Patient Care Begins: You complete your first assessment:
Current VS: P-Q-R-S-T Pain Assessment:
T: 98.6 F/37.0 C (oral) Provoking/Palliative: Breastfeeding
P: 76 (regular) Quality: Cramping and tenderness of perineum
R: 18 (regular) Region/Radiation: Uterus and perineum
BP: 125/80 Severity: 4/10
O2 sat: 98% room air Timing: When breastfeeding and continuous for perineum
