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Maternity Case 5: Amelia Sung (Core) Documentation Assignments 2021 $7.49
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Maternity Case 5: Amelia Sung (Core) Documentation Assignments 2021

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Maternity Case 5: Amelia Sung (Core) Documentation Assignments 2021

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  • March 19, 2022
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  • 2021/2022
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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.
Ms. Sung is a 36 y/o Filipino woman, G2P1 admitted approx. 6 hours ago in active
labor. She was 4cm dilated and 100% effaced and station -1. Epidural anesthesia
was initiated at 0230. The membrane ruptured at 0330 and the amniotic fluid was
clear. Since then she has dilation 6 cm and the fetus is presently at -1 in the vertex
position. She is fully dilated and began pushing. The fetal heart rate is within
normal limits with moderate deceleration. Fetal began to crown and was given O2
via nonrebreather mask at 10 L and LR running at 125ml/hr. Ms. Sung’s last baby
was a shoulder dystocia.

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.

16:55 Performed at vaginal exam. The head was crowning

05:12 Checked for blood, lochia and fluid on the bed

05:33 Changed and weight the bed pads

05:56 Notified NICU of risk

06:27 Prepared the delivery table

06:44 Prepared the bassinet

06:57 Check for presence of step stool in the room in case it is needed for suprapubic
pressure

07:10 Instructed patient to start pushing

07:14 Encourage pushing

07:33 Called the Charge Nurse

08:58 Repositioned the patient

10:01 Baby head was delivered

.


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