LaGuardia Community College Practical Nursing Program SCL 115 Maternity Child Health Nursing Antepartal Observations On a Patient with Threatened Prelabor Direction: Complete this observation chart by writing the appropriate value, observation and nursing intervention for each of the nursing assessment areas By Anaise E. Ikama Area of Nursing Assessment Normal P. P. State Describe your observations Nursing Interventions Para: 0010 with intact membrane, abdominal soft, nontender uterus and active fetus. Continuously assess the membrane, palpate the abdominal and assess fetal movement Para/Gravida status Depends on each patient VS/FH BP 120-140/80, P 60-80, T (should not exceed 100.4), FHR 110-160 BP 118/73, P 90, RR 20, T 98.2 and lower back pain (5/10), FHR 150 Massage and put some pressure at the lower back. Suggest that the patient, support her arms, feet, and back with pillow when sitting Calculation of EDC/ Gestational age Depends from the date of conception 11/20/07 and 36 weeks Teach client how to come up with the estimated date of delivery Mother’s weight Gain Signs and symptoms Should gain 15 to 25 lbs (7 to 11.5kg) Increase weight, ascends of the uterus into the abdomen. No frequent abdominal pain Active fetus Gained……. Total weight: 244 lbs Frequent abdominal pain, painless contraction Fetal movement Put the client on regular healthy diet Massage and put some pressure at the lower back. Administer meds as ordered: magnesium tocolysis and dexomethone as ordered to aid in fetal lung maturity Continuously assess the fetus Appropriate for client’s Trimester Normal Discomforts Danger signals Fatigue, lost interest of activities, unwelcome body changes. Obesity, threatened prelabor and immaturity of the fetal lungs Fatigue, lost interest of activities, unwelcome body changes Lower abdominal cramp, mild contraction every 4 minute, Increase in glucose level and Urinary Tract Infection Assure the woman that these changes are temporary. Help her explore expressions such as loving and caring. Put patient on partial bed rest; administer meds as ordered: magnesium tocolysis and dexomethone as ordered to aid in fetal lung maturity; Ampiciline for urinary tract infection. Assess vital signs, I/O Complications Ultrasound Gestational diabetes, hyperemesis graviderum, preeclampsia, placenta previa and abruptia, premature rupture of the membrane A shortened cervix Threatened premature labor Did not observe Observation/ Result OCT results NST Result Pertinent Lab Data Shows no deceleration of fetal heart rate during uterine contraction, which is interpreted as being negative 15 fetal beats per minute lasting for 15 to 20 seconds over a 20-minute period. Normal Magnesium level 1.5-2.5 Did not observe Did not observe Client’s actual magnesium level was 4.6; almost twice the normal range Administer terbutaline as ordered, continue maternal and fetal vital sign assessment; assess the woman pain using a pain scale, characteristic and intensity. Encourage the woman to verbalize her fears and concerns. Usually for a woman who is preterm labor, the nurse should position her on her side for better placenta blood flow For positive test result that cannot be corrected, the nurse should prepare the client for cesarean section delivery. If the result is abnormal, the nurse will prepare the patient for further evaluation of the baby by inducing contractions with an oxytocin Challenge Test, for example. Assess patient for any sign of weakness and drowsiness.