High-Risk Antepartum Case Study Comprehensive Nursing Essay Example

High-Risk Antepartum Case Study Comprehensive Nursing Essay Example

Case Study Preview

As the nurse on duty, I evaluated Mallory Polk in triage in the labor and delivery unit. MP is a 42-year-old unmarried African American woman who presented in the triage unit at 8 P.M at 32 weeks gestation with complaints of a persistent low, dull backache; increased vaginal discharge and pelvic pressure in her vagina for two days with some vagina spotting this evening when she went to the bathroom. Alison, the patient’s sister, accompanied her while the monitor showed Mallory was contracting every 5-7minutes. The FHR is in the 150s baseline with accelerations to 170s with moderate variability. She has received regular prenatal visits and is a tee –more total. Her prenatal laboratory results indicate blood type A+, Paid Plasma Reagin non-reactive (RPR NR) Group B Strep (GBS) negative, hemoglobin level (Hgb) 12.4, hematocrit (Hct) values at 32.1, and is Hepatitis negative.  The current essay explores what the nurse in the labor and delivery unit, together with the rest of the healthcare team, should do in six of the scenarios highlighted before the physician recommends the healthcare team to turn off the magnesium sulfate and anticipate a vaginal delivery after two days because of the advanced pre-term labor- a recommendation which MP agrees with as the last.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

Prenatal Care Summary

1. Mallory began prenatal care at 10 weeks’ gestation and receives regular prenatal care. She conceives after three attempts at in vitro fertilization. She has no prior medical complications and has experienced a normal pregnancy. Her first pregnancy was terminated at 6 weeks of gestation. She is allergic to shellfish and is allergic to sulfa drugs. An ultrasound at 12 weeks confirms a gestational age of 32 weeks.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)
2. Detail the aspects of your initial assessment and what you would report to her physician.

As the nurse on duty, one has to conduct the patient’s initial assessment when admitting MP to the labor and delivery unit.  The admission assessment entails the maternal health history, physical assessment, fetal assessment, laboratory findings, and the patient’s psychological status assessment (Toney-Butler, 2020). According to the aforementioned scholar, the nurse should ensure proper documentation, past medical history, pain assessment, allergies, and current medications. Other aspects to ensure safe storage of the patient’s valuables, orient the patient and family, check activities limits and need for mobility aids besides assessing falls using Morse Fall Risk and initiate fall precautions as per the institution’s policy. In addition to taking the vital signs, the nurse should also consider the psychosocial needs of the patient and any off-hand information from other departments. The nurse should report the findings of maternal status, description of uterine activity, assessment of fetal status, and description of the findings on the vaginal exam if any were performed.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

1. Within 40 minutes of arrival, you phone her physician, who is completing a delivery, and report your assessment findings. The physician comes to the unit in 10 minutes to evaluate Mallory. Based on her assessment, she orders an IV lactated Ringer’s 300-mL bolus, a CBC, and urinalysis clean catch; does a fetal fibronectin; and does a sterile vaginal exam that reveals her cervix is 2 cm dilated/75% effaced/0 station. Her physician orders a 4-g magnesium sulfate bolus over 30 minutes, then 2 g per hour. Betamethasone is to be given 12 mg now and to be repeated in 24 hours. An ultrasound is ordered for fetal size and position. Her physician discusses the plan of care for treatment of pre-term labor with Mallory and answers her questions, and Mallory agrees to the plan to attempt to stop the contractions and delay delivery.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)
2. What are your immediate priorities in nursing care for Mallory?

Conduct tests and procedures to diagnose pre-term labor. The healthcare provider should be guided by the findings of the nurse’s review of the patient’s medical history and the risk factors for pre-term labor and evaluate her signs and symptoms. The tests and procedures include a pelvic exam, an ultrasound, uterine monitoring, and lab tests.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

• Discuss the rationale for the priorities.

A pre-term labor diagnosis is appropriate if a pregnant woman is experiencing regular contractions and the cervix has begun to soften , thin, and dilate before 37 weeks of gestation.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

• State nursing diagnosis, expected outcome, and interventions related to this problem.

Pre-term diagnosis, if confirmed, poses several potential adverse outcomes to both the mother and the fetus if not appropriately attended to. Death of the newborn could happen while survivors face a lifetime of disability that include but are not limited to cerebral palsy, impaired learning, vision problems, amongst others. Once a patient has gone into labor, there are no medications or surgical procedures to stop the labor. Be that as it may, the physician can prescribe medications that can temporarily stop the labor. Corticosteroids can be prescribed to promote the newborn’s lung maturity, and delivery is likely within seven days while the pregnancy is in 23- 34 weeks of gestation. Magnesium sulfate could be offered as it has been shown to reduce the risk of developing cerebral palsy in babies born before 32 weeks. Tocolytics can also be prescribed to slow the contractions for about 48 hours.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

• List Mallory’s risk factors for pre-term labor.

MP has several risk factors for pre-term labor, beginning with a history of pre-term delivery at six weeks of gestation, the pregnancy that resulted from IVF, and her advancing age as she is above 35 years (Gurung et al., 2020)(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

• What teaching would you include?

The patient and her sister would receive patient and family education on recognizing the symptoms of pre-term labor, like 4or more contractions per hour, persistent menstrual-like cramping, low back pain, and bleeding or spotting in the second or third trimester. Other components of the patient education would include measures that would help prevent premature birth like tobacco and tobacco products avoidance or cessation. Avoiding alcohol and taking a balanced diet with foods rich in folic acid and iron.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

1. Within 10 minutes of starting the magnesium sulfate bolus, she reports feeling hot and flushed and feels burning at the IV site. After the magnesium sulfate bolus is complete, you start the magnesium sulfate infusion at 2 g per hour. At midnight, her contractions slow down to every 15 minutes or 4–5 contractions/hour. The FHR baseline is 140s with minimal variability and periodic accelerations. An ultrasound reveals the fetus is vertex, estimated fetal weight (EFW) is 1,560 g, and fetal fibronectin is positive.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)
2. What are the assessments for a woman treated for pre-term labor on magnesium sulfate?

Safe administration of magnesium sulfate for pre-term labor includes taking the vital signs (temperature, pulse, blood pressure, respiratory rate pattern, levels of consciousness, breath sounds, and deep tendon reflexes).(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

• Discuss the rationale for the assessments.

The vital signs should be monitored for signs and symptoms of magnesium sulfate toxicity, respiratory depression, hypothermia, and circulatory collapse.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

• What teaching would you include in the nursing action plan?

The nurse educator should include content that addresses magnesium sulfate drug interactions, drug incompatibilities, and the need to check for serum magnesium before the selected drug’s administration. Additionally, there is a need for cardiac monitoring where magnesium sulfate is administered intravenously.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

1. At 7 A.M. when you sign off, Mallory is sleeping intermittently. Her contractions are 2–3 per hour and the FHR is reassuring. Mallory is very concerned about giving birth to a premature baby. She is concerned that a baby will not survive at this gestation and states, “I have always wanted to be a mother and was so happy when I was finally ready to have a baby and conceived with IVF.” She is worried about not being able to return to work over the next few days and weeks, as she has many active cases pending over the next few weeks. She states that she is not ready for the baby to come and has not set up the crib or finished the nursery. She feels guilty that she did not come to the hospital sooner and considered the backache as just part of pregnancy discomforts. Before you leave, you have requested Mallory be seen that day by the neonatal clinical specialist to review status and care for neonates born prematurely and to have Mallory’s sister tour the NICU.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)
2. Detail the aspects of your psychosocial assessment for a woman with a high-risk pregnancy.

A psychosocial assessment for a woman with a high-risk pregnancy reveals factors like stress, marital discontent, anxiety and depression, and social support.  Additionally,  Spyridou et al. (2015) contend that these are directly linked to the six domains of a healthy lifestyle of the pregnant woman through effective stress management, physical activity, health responsibility, nutrition, and physical activity. Self- actualization and interpersonal relationships complete the list of six healthy lifestyle domains.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

• Discuss the rationale for the assessment.

Omdivar et al. (2018) define healthy lifestyles as patterns of self-initiated behaviors and perceptions that lead the individual to maintain their level of wellbeing. Mallory’s emotional wellbeing is likely to affect by greater anxiety levels on whether she will carry the pregnancy to a full term and the frequent interventions to monitor fetal growth. The CBC test also reveals she has anemia or, at best, suffering from iron deficiency, thus putting her pregnancy in the high-risk group.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

• Discuss nursing diagnosis, nursing actions, and expected outcomes related to this psychosocial assessment.

Iron deficiency can be addressed by MP taking foods rich in iron or even taking iron and other essential vitamins and mineral supplements.  Other nursing actions include nonpharmacological interventions to manage her anxiety levels. The patient should consider taking exercises and engaging in physical activities to bring her anxiety levels down. Once she manages her anxiety levels and is assured that her pregnancies in the future will be normal. Taking a balanced diet where all her nutritional needs are met will also improve the outcomes of future pregnancies.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

• The next night, you come onto your shift at 7 P.M. and care for Mallory again. She remains on the magnesium sulfate and appears to be tolerating the medication. Her magnesium level is5.6 mEq/L. She still feels warm and somewhat lethargic with sore muscles due to being in bed all day. She is due for her second dose of betamethasone. Her I&O for the past 24 hours are: I: 2,500 mL; O: 2,300 mL. The plan is to wean her off the magnesium sulfate in the next 2 days and transfer her to the antenatal unit in the morning.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)
• Detail the aspects of your ongoing assessment for a woman treated with magnesium sulfate and diagnosed with pre-term labor.

Magnesium sulfate is the most commonly used drug to treat pre-term labor. In the US. The nurse needs to monitor the patient’s EKG and respiratory status and magnesium levels  

• Discuss the rationale for the assessment.

Magnesium sulfate may cause depressed respiratory rate, arrhythmias, and muscle weakness. Besides ensuring correct dosage with a secondary practitioner, the nurse should be aware that magnesium toxicity may lead to loss of deep tendon reflexes while calcium gluconate is a magnesium toxicity antidote.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

• At 0320 she reports feeling a gush of fluid from her vagina after a strong contraction. Between her legs is a large amount of clear fluid. The FHR is baseline 140s with minimal variability and accelerations. Mallory appears frightened and anxious. She is crying and her sister is at her side holding her hand and reassuring her.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)
• What are your immediate priorities in nursing care for Mallory?

The pre-term delivery is imminent, and Mallory is in the first stage of labor, where dilation of the cervix occurs. The nurse should examine the cervix to ensure it is fully dilated about (10 cm) for the baby to pass through. Dilation of the cervix commences from the moment the contractions start to when the cervix is fully dilated. During the second and third phases of the first stage in labor, the nurse may administer pain medication depending on the intensity of the pain. The team should be ready for the second stage of labor –delivery and the third stage, which is the release of the afterbirth and finally recovery as the fourth and final stage.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

• Discuss the rationale for the priorities.

The priorities are in line with the four stages of labor, namely the first stage (cervix dilation), the second stage (newborn delivery), the third stage (release of the afterbirth), and finally, stage four recovery.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

• Within 45 minutes, her physician comes in to see Mallory and does an SVE. She is 5 cm, 90% effaced, and +1 station, an ultrasound reveals the fetus is the vertex. The physician recommends turning off the magnesium sulfate and anticipating a vaginal birth because of the advanced pre-term labor. Mallory agrees with the plan.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

References

Crowther, C. A., Middleton, P. F., Wilkinson, D., Ashwood, P., & Haslam, R. (2013). Magnesium sulfate at 30 to 34 weeks gestational age: neuroprotection trial (MAGENTA)-study protocol. BMC pregnancy and childbirth, 13(1), 1-9.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

Gurung, A., Wrammert, J., Sunny, A. K., Gurung, R., Rana, N., Basaula, Y. N., … & Ashish, K. C. (2020). Incidence, risk factors, and consequences of pre-term birth–findings from a multi-centric observational study for 14 months in Nepal. Archives of Public Health, 78(1), 1-9.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

Omidvar, S., Faramarzi, M., Hajian-Tilak, K., & Nasiri Amiri, F. (2018). Associations of psychosocial factors with pregnancy healthy lifestyles. PloS one, 13(1), e0191723.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

Spyridou, A., Schauer, M., & Ruf-Leuschner, M. (2015). Obstetric care providers can assess psychosocial risks and identify and refer high-risk pregnant women by validating a short assessment tool–the INDEX Greek version. BMC pregnancy and childbirth, 15(1), 1-17.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

Toney-Butler, T. J., & Unison-Pace, W. J. (2018). Nursing admission assessment and examination.(High-Risk Antepartum Case Study Comprehensive Nursing Essay Example)

https://www.ncbi.nlm.nih.gov/