Primary Concept
Reproduction
Interrelated Concepts (In order of emphasis)
• Clotting
• Clinical Judgment
• Communication
NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in Ca
...
Primary Concept
Reproduction
Interrelated Concepts (In order of emphasis)
• Clotting
• Clinical Judgment
• Communication
NCLEX Client Need Categories Percentage of Items from Each Category/Subcategory Covered in 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%
• Reduction of Risk Potential 9-15%
• Physiological Adaptation 11-17%
Part I: Recognizing RELEVANT Clinical Data
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:
Uterus firm and one finger breadth below umbilicus and midline
Moderate rubra lochia
Midline episiotomy with slight bruising and swelling
Voiding without difficulty, 500mL in/850 out
B- GBS+
Baby has breast fed and latched on for five minutes on both sides three times
Anne is holding and talking to her baby. Expected finding. If elevated above the umbilicus and/or deviated to the right, then indicate full bladder and could lead to boggy uterus with increased bleeding.
Expected finding. More than 1pad an hour bleeding is heavy, and uterus needs to be massaged.
Expected finding. Continue to monitor for any increasing swelling or bruising that could indicate hematoma.
Expected finding. Increased urine output is related to increased blood volume and since the need for blood volume is decreased then the body gets rid of the extra via the kidneys. Continue to monitor.
Will need to follow up and find out baby’s blood type. If the baby is Rh positive, Anne will need Rhogam within 72 hours.
Received ampicillin during labor but still need to monitor baby for signs of infection that include grunting, retracting, nasal flaring, poor feeding, listlessness, hypoglycemia, hypothermia.
Baby has fed an adequate amount as a newborn.
Interaction with the baby indicates that appropriate bonding and
........................CONTINUED
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