The nurse is caring for a patient in OB triage in active labor. Use the chart to answer the questions. The chart may update as the scenario progresses.
HISTORY AND PHYSICAL ASSESSMENT:
Medical/Surgical history: Patient is a 29-year-old African American female, G4P2012, at 39.5 weeks. EDD is 4/03/XX based on first trimester ultrasound. Patient is compliant with prenatal appointments and care recommendations, and has had no complications with pregnancy.
? First pregnancy 5 years ago: IVF pregnancy. SVD at 40.3, first degree laceration, no other complications, 3,285 g viable female.
? Second pregnancy 3 years ago: IVF pregnancy. SVD at 38.6 weeks, no complications, 3,420 g viable male.
? Third pregnancy 18 months ago: IVF pregnancy. SAB at 10 weeks, unknown pathology.
Social history: Nonsmoker, nondrinker, no history of drug use. Is an elementary school teacher. States marriage is stable and happy with no concerns. Wife is an active-duty naval officer, currently deployed in the Mediterranean. Has family in the area for support, including two sisters and her parents.
Family History: Maternal and paternal history of hypertension. Paternal hyperlipidemia. Maternal depression, well controlled with medication. No other concerns.
Physical Assessment: Pre-pregnancy—height 5’11”, weight 168 lb, BMI of 23. Current weight 194 lb. NST is reactive, FHR baseline 140 bpm with contractions every 2 to 4 minutes, moderate intensity on palpation. SVE 5/80/0, membranes intact.
NURSINGS NOTES
4/01/XX
1428
Patient ambulated to OB triage with sister at her side. States contraction pain woke her around 0630 this morning, but labored at home until they became more frequent.
1450
Provider contacted with report and recommendation for admit. Patient admitted to labor and delivery unit per provider orders. Patient ambulated to room, oriented to room and care plan. Placed on FHM, US above umbilicus on the right side. 18-gauge INT placed in RFA (right forearm), CBC and type cross labs drawn and sent to lab.
1510
Patient states she felt a gush of fluid during a contraction. Pericare performed. Fluid noted to be clear and copious.
1528
Patient states she feels the urge to push. Provider notified and room prepared for delivery.
1532
Provider at bedside. Patient is open glottis, involuntarily pushing. Tarry, black discharge is noted at the vaginal introitus. The provider palpates the presenting part, and calls for an urgent cesarean section.
VITAL SIGNS:
4/01/XX
1445
Temp 98.4°F (36.9°C)
HR 82 beats/min; regular
RR 22 breaths/min
SpO2 100% on room air
Blood pressure 123/69 mm Hg
Pain 0 on 1-10 scale when not contracting, 7/10 during contractions
Question
The nurse is now the circulating nurse in the OR. Which of the following actions are now the nurse’s responsibility? Select all that apply.
- Explain the surgical procedure and gain consent.
- Apply sequential compression devices (SCDs) prior to surgery
- .Monitor vital signs and oxygen saturation.
- Manually remove the placenta.
- Insert Foley.
- Place wedge to tilt the patient left lateral.
- Administer antibiotics and Pitocin during the procedure.
- Perform abdominal skin prep using sterile technique.
- Monitor and determine the QBL.
- Perform instrument, needle, and sponge counts.