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vSim_Maternity_Scenario
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vSim_Maternity_Scenario
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Clara Guidry Room 301Clara Guidry, Patient is a 34 y/o G5P4 who gave birth to a 9lb. 3 oz male
infant following a 12-hour elective oxytocin induction of labor. She had an
uncomplicated labor, epidural anesthesia and a rapid second stage, no
episiotomy or perineal lacerations. Indwelling urinary catheter was removed
prior to delivery. She is now one hour postpartum and is breastfeeding her
baby. An IV of 1000 mL Lactated Ringers is infusing at KVO rate with an
infusion of Lactated Ringers with oxytocin 20 Units infusing IVPB at 125
mL/hour. Upon entering her room, she tells you that she “feels wet”, and may
have urinated on herself since she is still numb from the epidural and unable
to move legs. Your assessment reveals blood pooling under buttocks onto the
underpads with numerous large clots. She is anxious, appears pale, and
complains of feeling light-headed. Her husband is at her bedside.
You responded correctly to 3 out of 6 evaluations:
Category Your response Explanation
-Educational Needs Increased acuity Status assessment reports uterine atony and bleeding
and need for fundal massage.
-Fall Risk Increased acuity Status assessment reports patient is still numb from epidural
and unable to move legs.
-Health Change Increased acuity Status assessment reports pooling of blood with large clots.
-Pain Level Normal acuity Status assessment does not indicate report of pain and patient is still
under effects of epidural anesthesia.
-Psychological Needs Increased acuity Status assessment reports pooling of blood, patient
reports feeling light-headed, appears pale, indwelling urinary catheter removed and patient unable to
sense need to void.
-Sensorium Increased acuity Status assessment reports patient reporting feeling light-headed
and still numb from epidural and is feeling anxious.
Clara Guidry
Patient is a 34 y/o G5P4 who gave birth to a 9lb. 3 oz male infant following a
12-hour elective oxytocin induction of labor. She had an uncomplicated labor,
epidural anesthesia and a rapid second stage, no episiotomy or perineal
lacerations. Indwelling urinary catheter was removed prior to delivery. She is
now one hour postpartum and is breastfeeding her baby. An IV of 1000 mL
Lactated Ringers is infusing at KVO rate with an infusion of Lactated Ringers
,with oxytocin 20 Units infusing IVPB at 125 mL/hour. Upon entering her room,
she tells you that she “feels wet”, and may have urinated on herself since
she is still numb from the epidural and unable to move legs. Your assessment
reveals blood pooling under buttocks onto the underpads with numerous
large clots. She is anxious, appears pale, and complains of feeling light-
headed. Her husband is at her bedside.
Assigning Nursing Concern
You correctly diagnosed 9 out of 13 options:
Physiological
Description Your Response Explanation
-Acute Pain False Status assessment reports lingering numbness from epidural.
-Bleeding True Status assessment reports blood pooling under buttocks with large clots, most
likely secondary to uterine atony because of multipara status, rapid second stage, oxytocin use and large
infant.
-Deficient fluid volume related to uterine atony/postpartum hemorrhage True Status
assessment reports blood pooling under buttocks with large clots.
-Impaired mobility True Status assessment reports effects continued numbness from epidural.
-Impaired patterns of elimination True Status assessment reports continued numbness from
epidural with urinary catheter having been removed previously; patient unable to sense a full bladder
which can contribute to uterine atony and hemorrhage.
-Ineffective tissue perfusion related to hypovolemia True Status assessment reports blood
pooling under buttocks and large clots, feeling anxious and light-headed and appears pale
-Infection False Status assessment reports no indication of a current infection.
-Nausea False Status assessment reports no indication of increased risk.
Safety
Description Your Response Explanation
-Deficient knowledge True Status assessment reports patient reports feeling wet and may have
urinated on self and still numb from epidural; unaware of potential for uterine atony and hemorrhage,
client and husband both require education and support.
-Disturbed sensory perception True Status assessment reports patient is still numb from epidural.
, -Fall, risk for self and risk for dropping baby True Status assessment reports lingering numbness
from epidural and unable to move legs; reports feeling light-headed
-Impaired maternal newborn bonding False Status Assessment reports mother is currently holding
and breastfeeding baby.
-Peripheral Neurovascular Dysfunction False Status assessment reports no indication of increased
risk.
Clara Guidry Scenario 1
You enter the patient’s room. After washing and gloving hands, you introduce
yourself and verify identities of the patient, Mrs. Clara Guidry and the baby.
Assessment findings: Blood pooling under buttocks with several large clots;
fundus boggy and slightly deviated to the right, 3 cm. above umbilicus; Vital
signs: BP 90/60, P 110, R. 20, SAO2 98%, skin color pale, patient alert and
oriented; unable to move legs, holding and breastfeeding baby. SELECT THE
FIRST TWO NURSING ACTIONS IN THE ORDER THAT THEY SHOULD BE
IMPLEMENTED:
Patient care scenario:
Drag the following actions into the correct order. (The first item should be on top.)
You correctly ordered 1 out of 5 actions:
Your order Correct order Step Explanation
1 1 Assist mother to unlatch infant from breast and place infant in crib or hand to the
husband.
Explanation: Patient is light-headed and hypovolemic putting infant at risk of falling from
mother’s arms. Infant safety is a first priority.
5 2 Massage uterine fundus.
Explanation: Massaging the fundus until firm and tightly contracted closes off blood vessels at
the placental site and stops bleeding.
2 3 Call for help using emergency call system.
Explanation: Postpartum hemorrhage is the leading cause of morbidity and mortality requiring a
rapid, team approach to patient management.
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