Exam (elaborations)
Swift River Maternal-Newborn With complete solution | Updated 2024/25
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Swift River Maternal-Newborn With complete solution | Updated 2024/25
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Swift River Maternal-Newborn Withcomplete solution | Updated 2024/25
Miranda Johnson - Educational Needs - Increased acuity
II II II II II II II II II
Fall Risk - Increased acuity: Related to pregnancy and changes in balance and center of
II II II II II II II II II II II II II II
gravity.
II
Health change - Increased acuity: Related to active labor and change in health status.
II II II II II II II II II II II II II
Pain level - Increased acuity: Related to increased pain level of 7-8 out of 10.
II II II II II II II II II II II II II II
Physiological Needs - Increased acuity: Related to active labor, increased pain, and II II II II II II II II II II II
desire for epidural.
II II II
Sensorium Needs - Normal acuity II II II II
Miranda Johnson - Risk for Impaired Urinary Elimination
II II II II II II II II II II
Risk for Maternal Injury
II II II
Deficient knowledge II
Risk for Fall II II
Miranda Johnson - Scenario 1:
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1. Review prenatal record
II II II II
2. Witness signing of epidural
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3. Initiate IV bolus per order
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4. Gather epidural medications
II II II
5. Monitor patient
II II
Scenario 2: II II
1. Educate patient
II II
2. Assess maternal and fetal wellbeing
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3. Encourage repositioning
II II
4. Reassess patient's understanding
II II II
Scenario 3: II II
1. Turn epidural pump off.
II II II II
2. Lower HOB, elevate foot
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3. Rapid infusion (bolus)
II II II
4. Apply NRB 10L
II II II
5. Consider administration of Ephedrine.
II II II II
Scenario 4: II
1. Continually monitor
II II
, 2. Administer Ephedrine
II II
3. Notify the charge nurse
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4. Administer pre-op meds
II II II
5. Offer reassurance
II II
Scenario 5: II
1. Maintain efficient, timely
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2. Thoroughly document
II II
3. Discuss patient load
II II II
4. Always sign out
II II II
5. NEVER ASSUME ANYTHING
II II II
Carly Madison - Educational Needs - Increased acuity: Status assessment reports she is
II II II II II II II II II II II II II II II
a G1 having attended childbirth classes, but first-time mothers require focused education
II II II II II II II II II II II II
and reinforcement of concepts learned.
II II II II II
Fall Risk - Normal acuity
II II II II
Health change - Normal acuity II II II II
Pain level - Increased acuity: Status assessment indicates a pain level of 4/10, desiring an
II II II II II II II II II II II II II II
unmedicated birth.
II II
Physiological Needs - Increased acuity: Status assessment indicates that the client is in II II II II II II II II II II II II
labor.
II
Sensorium Needs - Normal acuity II II II II
Carly Madison - Acute Pain
II II II II II II II
Anxiety Related to Labor and Birthing ProcessII II II II II II
Fatigue Related to Energy Expenditure Required for Labor and Coping Skills
II II II II II II II II II II
Impaired Comfort II
Risk for Fluid Volume Deficit
II II II II
Deficient Knowledge II
Maternal Infection II
Carly Madison - Scenario 1:
II II II II II II II
1. Offer support and explain
II II II II
2. Assess the FHR
II II II
3. Place a clean, dry pad
II II II II II
4. Assist the HCP
II II II
5. Reassess the FHR
II II II
Scenario 2: II
1. Reassure client
II II
2. Assist woman to restroom
II II II II
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