What instructions should be included for follow-up visits and signs of potential complications?

Words: 433
Pages: 2
Subject: Nursing


Obstetric Case Study

M.S. is a 46 y/o African American who presents to the prenatal clinic alone for her second visit. Her last LMP was 07/22/20. This is pregnancy number six. She had deliveries at 34.3, 36.2, 38.5 and 37.6 weeks and a spontaneous abortion with a dilatation and curettage at 8 weeks in 2006. She reports mild contractions that started the previous evening. She took Motrin twice to stop the pain and had good results.

She has no vaginal bleeding and feels the baby moving; She also reports nasal stuffiness, and not feeling like eating breakfast on most mornings; her antepartum course has been significant for prenatal labs with an elevated glucose challenge test followed by a normal glucose tolerance test and a brief hospitalization @ 22 weeks for dehydration due to gastroenteritis.

Her Gyn history: she was diagnosed with HPV in 1994, and has no fibroids or ovarian cysts; her past medical history is significant for hypothyroidism, and her medications include Synthroid 88 mcg, prenatal vitamins; she gets a rash from sulfa containing medications, and a family history is significant for a maternal grandfather with CHF and a paternal aunt with post-menopausal breast cancer; her social history is significant for a 15 pack-year history of smoking cigarettes ending prior to her first pregnancy; no alcohol or drugs; her review of systems is significant for generalized fatigue and constipation.

Physical exam: she is alert and in mild discomfort with contractions; vital signs are stable; there is murmur loudest over the left lower sternal border; her abdomen is soft, gravid and non-tender; fundal height is 30 cm, NST reactive, vaginal exam is 2 cm/40% /-2; the fetal heart rate has a baseline of 130’s with accelerations and no decelerations; there are 30 second contractions every six minutes; extremities have no edema. Terbutaline was ordered and she has not had any contractions for 24 hours. Pt was sent home with instructions.

1. Calculate her EDD/EDB. – Show calculation

2. What is her gestational age?

3. Document her pregnancies. Use the 5-digit and the 2-digit methods.

4. List 3 NANDA diagnoses (include related to and AEB). List two interventions for each nursing diagnosis with rationales (cite source).

5. What are risk factors for this patient?

6. Is this pregnancy progressing normally? – include supporting data

7. List the medications the patient is taking.

a. Are these medications appropriate? If no, which ones? Provide rationale.

b. What are the nursing responsibilities for each medication?

8. You are preparing a teaching plan for this patient. What are the points that you would include based on the scenario?

9. What are the nursing responsibilities for this patient?

10. What instructions should be included for follow-up visits and signs of potential complications?