Case 2.docx - CASE 2 BRENDA PATTON 1 Document your initial...

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CASE 2: BRENDA PATTON 1. Document your initial assessment data of Ms. Patton, including uterine activity (frequency and duration), fetal heart rate (FHR) activity (baseline FHR, long-term variability, accelerations, and decelerations), vaginal discharge, and maternal vital signs. Patient status - Heart rate: 90. Pulse: Present. Blood pressure: 119/71 mmHg. Respiration: 20. Conscious state: Appropriate. SpO2: 97%. Temp: 37 C. EFM: Baseline. Fetal heart rate: 141. I examined the patient abdomen and pelvis. Leopold maneuvers were performed. The fetus is in longitudinal lie, in vertex presentation. Palpated the uterus for contractions. The uterus tone was soft between contractions. Regular contractions with moderate intensity had started. Contractions were approximately 4 minutes apart and lasting 50 seconds. 2. Document the medication(s) that you administered. I started an infusion of 5000000 IU of penicillin IVPB. It is important to use the basic rights of medication administration to ensure proper drug therapy. I also started a piggyback infusion of 12.5 mg of promethazine IV.

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