Maternity Case 4: Brenda Patton (Complex)

Documentation Assignments

1. Document your initial assessment data of Ms. Patton, including uterine activity (frequency
and duration), fetal heart rate (FHR) activity (baseline FHR, long-term variability,
accelerations, and decelerations), vaginal discharge, and maternal vital signs.
Brenda Patton status were as follows: Heart rate: 105. Pulse: Present. Blood pressure: 123/74
mmHg. Respiration: 20. Conscious state: Appropriate. SpO2: 97%. Temp:39.2 C. EFM:
Baseline. Fetal heart rate: 180. Vaginal Discharge was present.
2. Document the medication(s) that you administered.
Piggyback infusion of 2 g of cefazolin IV.
Acetaminophen of 1000g was administered for her temperature
Promethazine IV 12.5mg was given piggyback

3. Document Ms. Patton’s pain during labor (severity during contractions, location, quality,
interventions taken, and response to interventions) and the measures that were taken to
promote her desire for a natural birth.
Location—abdominal pain and pressure due to contractions. Pain level 2/10 that radiates to back
Patient responded and tolerated all interventions—med administration, assessment, and exams.
No pain medications were given or mechanical interventions preformed to induce labor only
non-pharmacological interventions for pain and discomfort management which helped to
promote a natural birth for the patient . Comforting interventions with communication were
implemented during painful contractions and palpation of each contraction.

4. Document in situation-background-assessment-recommendation (SBAR) format your

communication to the provider regarding Ms. Patton’s status and note her future care needs.

Brenda Patton is an 18-year-old Caucasian female, G1P0 at 38 2/7 weeks of gestation admitted
to the labor and birthing unit for labor assessment due to spontaneously ruptured membrane.
The patient wishes to have a natural birth without any use of epidural.
Patient is feeling nauseas has a raspatory rate of 23. NICU must be notified regarding her baby.
Fetal heart is at 188. Patient vital signs are Heart rate: 100. Pulse: Present. Blood pressure:
131/79 mmHg. Respiration: 24. Conscious state: Appropriate. SpO2: 98%. Temp: 39.1 C. EFM:
Occasional acceleration. Continue to administer medications such as promethazine,
Acetaminophen and cefazolin.

From vSim for Nursing | Maternity. © Wolters Kluwer Health.

5. Document the informal patient education that you provided Ms. Patton during this scenario
regarding group B streptococcus and the patient’s response to this teaching session.
I provided education regarding Group B streptococcal (GBS) and the necessary protocols the
nurses need to follow to help Brenda and her unborn baby have a safe and healthy delivery. We
provided information regarding the medications needed and how to ease her pain during
contractions.

From vSim for Nursing | Maternity. © Wolters Kluwer Health.