1. Document your inital assessment data for Ms. Sanogo, including vital signs, fundal
assessment (consistency, positon, locaton), lochia assessment (amount, color, odor,
consistency), and pain (locaton, quality, severity).
ANSWER:
a. Pulse: Present, Blood pressure: 101/51 mmHg, Respiraton: 18. Conscious state:
Appropriate, SpO2: 97%, Temp: 37 C; 20 breaths per minute – chest moving
equally;
PERRLA and pupils 7mm; heavy red present lochia on pads/bed suggestng
1190 mL of lochia was on the pads; uterus was sof and boggy; pain of 5 out of
10 on 1 to 10 scale located in the abdomen
2. Write the situaton-background-assessment-recommendaton (SBAR) communicatons you
would use to update the provider on Ms. Sanogo’s status afer your frst encounter with her.
ANSWER:
a. S: Ms Sanogo, heavy blood and lochia present suggestng postpartum hemmorage
b. B:14 hours postpartum - delivered 9 lb baby at 0605; had a 2nd degree perineal
laceraton repair afer prolonged labor
c. A: Patent status/VS: Heart rate: 112. Pulse: Present. Blood pressure: 94/49 mmHg.
Respiraton: 21, chest moves equally; Conscious state: Appropriate. SpO2: 95%. Temp:
37
C; heavy bloody lochia present on pads and bed; performed fundal massage; uterus did
not frm up properly; is sof and boggy. Afer changing/weighing the bed pads; increase
in weight of the bed pads suggests that approximately 1190 mL of lochia was on the
1
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