MaternityCase1_DA.docx - Maternity Case 1 Olivia Jones...

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Maternity Case 1: Olivia Jones Documentation Assignments 1. Document the data from your focused antepartum assessment of both Ms. Jones and the fetus. Patient status - Heart rate: 115. Pulse: Present, strong. Blood pressure: 174/104 mmHg. Respiration: 22. Conscious state: Appropriate. SpO2: 89%. Temp: 99 F. EFM: Occasional acceleration. Pt c/o of pain, rated 5. Pain is across forehead and c/o of epigastric pain. Pt. has normal elasticity of the skin and she is cool and very sweaty. She is breathing at 22 breaths per minute. The chest is moving equally. Leopold maneuvers were performed. The fetus is in longitudinal lie, in vertex presentation. Pt has moderate to severe pitting edema, graded to +3. Crackles at both lung bases upon auscultation. FHR is 165 bpm, fetus is tachycardic. Deep tendon reflexes were very brisk, hyperflexive, and with clonus, graded to +4. Palpation of uterus: uterus tone is moderate between contractions. No contractions were noted. Fetal movement was felt. IV site has no redness, swelling, infiltration, bleeding, or drainage. The dressing is

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