Maternity Case 2: Olivia Jones (Complex)Documentation Assignments1.
Document the data from your focused antepartum assessment of both Ms. Jones and the fetus. On initial antepartum assessment of Ms. Jones and the fetus seizure precautions were initiated and outside stimuli minimalized. A head to toe assessment was performed and vital signs obtained HR 113, BP 171/103, RR 22, SpO2 92%, Temp 99 F, FHR 153. There is normal elasticity of the skin, her skinis cool and she is very sweaty. There is a moderate to severe pitting edema +3. 100% oxygen at 10 L/min via non-rebreather face mask has been initiated. Pt states she has a headache that’s a 5 on a scale of 0-10, epigastric pain that is a 4 on a scale of 0-10. Deep tendon reflexes graded to +4, very brisk, hyperreflexive, and with clonus. A bladder scan was performed that showed 82 mL in the bladder. A urinary catheter has been placed to monitor I&O. The EFM has been attached with routine FHR monitoring by doppler/auscultation, current FHR 150 EFM Baseline. The uterus was palpated for contractions with none noted, fetal movement was felt. An ultrasound examination was performed that was normal. The provider was contacted and orders were placed for magnesium sulphate in sterile water (6 g in 100 mL) at 200 mL/hr as a loading dose and magnesium sulfate 20 g in 500 mL sterile water at 50 mL/hr following loading dose. HR 102, BP 168/101, RR 22, SpO2 98%, Temp 99F,