Carla Hernandez Documentation.docx - Maternity Case 4 Carla...

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Maternity Case 4: Carla Hernandez Documentation Assignments1.Document your initial assessment data for Carla Hernandez, including fetal heart rate activity (baseline fetal heart rate, long-term variability, accelerations, and decelerations) and maternal vital signs.32 year old female, no known allergies. G2P1, at 39 5/7 weeks of gestation. Inactive labor at 0600 hours, accompanied by husband. Pt status: A&O x4, HR 90, BP 137/82, SpO2 98%, FHR 89, bradycardic, recurrent late decelerations with declining variable, showing sinusoidal pattern; Category III; abnormal FHR. Pt given 500 mL bolus of Lactated Ringers, FHR decreased to 72 bpm. Vaginal exam performed, prolapsed umbilical cord. Pressure relieved by nurseusing sterile glove hand. Pt given 0.25 subq terbutaline. Provider called. Prepped pt for cesarean.2.Document the medication(s) that you administered.500 mL bolus of Lactated Ringer’s0.25 subq Terbutaline3.Document your situation-background-assessment-recommendation (SBAR)

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