Handout 1: Case Study: High-Risk Antepartum Nursing Care As the nurse, you evaluate Mallory Polk in triage in the labor and delivery unit. She 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 vaginal spotting this evening when she went to the bathroom. She attributed the discomforts of backache and pulling to working long hours for the past week in arbitration on a “big case,” because she is a partner in a large law firm. Mallory is a 42-year-old single African American woman. She is accompanied by her sister Alison, who is visiting for the week from out of state. When placed on the monitor, Mallory is contracting every 5 to 7 minutes that she reports as “menstrual cramping.” The FHR is in the 150s baseline with accelerations to 170s with moderate variability. A review of her prenatal record reveals she is a G2 PO and the pregnancy is a result of in vitro fertilization. She has received regular prenatal visits. She does not smoke or drink alcohol. Her prenatal laboratory results are as follows: Blood type A+ . RPR NR GBS negative Hgb 12.4 Hot 32.1 Hepatitis negative Prenatal Care Summary 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. 1. Detail the aspects of your initial assessment and what you would report to her physician. wine examinat! (vital sign presence of ling/edena the 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 a urinalysis clean catch; does a fetal fibronectin; and does a sterile vaginal exam that reveals her cervix is 2 cm dilated/75% effaced/O station. Her physician orders a 4- 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. Ampicillin 1 g is ordered IV every Coul 6 hours, Her physician discusses the plan of care for treatment of preterm labor with Mallory and answers her questions, and Mallory agrees to the plan to attempt to stop the contractions and delay delivery. 2. What are your immediate priorities in nursing care for Mallory? Discuss the rationale for the priorities monitor closely tor sign gretol or maternal distress 3. State nursing diagnosis, expected outcome, and interventions related to this problem 4. List Mallory's risk factors for preterm labor. 5. What teaching would you include? 6. What are the assessments for a woman treated for preterm labor on magnesium sulfate? Discuss the rationale for the assessments. 7. What teaching would you include in the nursing action plan? At 7 a.m. when you sign off, Mallory is sleeping intermittently. Her contractions are 2 to 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 11 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. 8. Detail the aspects of your psychosocial assessment for a woman with a high-risk pregnancy. Discuss the rationale for the assessment 9. Discuss nursing diagnosis, nursing actions, and expected outcomes related to this psychosocial assessment. The next night, you come onto your shift at 7p.m. and care for Mallory again. She remains on the magnesium sulfate and appears to be tolerating the medication. Her magnesium level is 5.6 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 l&o for the past 24 hours are: 1:2,500 ml: 0:2,300 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. 10. Detail the aspects of your ongoing assessment for a woman treated with magnesium sulfate and diagnosed with preterm labor. Discuss the rationale for the assessment, 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. 12 11. What are your immediate priorities in nursing care for Mallory? Discuss the rationale for the priorities. Within 45 minutes, her physician comes in to see Mallory and does an SVE. She is 5 cm, 90% effaced, and +1 station, and an ultrasound reveals the fetus is vertex. The physician recommends they turn off the magnesium sulfate and anticipate a vaginal birth because of the advanced preterm labor. Mallory agrees with the plan.
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