Tammy Bailes
Mellanie Hopkins
Tiffany Kent
Christen Miller
Mother’s Profile
 L.S.
 Age 24
 Reason for admission – delivery
 Former ½ pack per day smoker
 No alcohol or drug use
 No prenatal classes
Medical History
 History of depression
 Cyst on ovary at age 14
 Arm surgery as child
 Victim of domestic violence by parents
 G1P0
 EDD 1/31/09
 Weeks gestation 40.5
Prenatal Lab Data
Prenatal Test
Norms
Patient Results
Analysis
Type & Rh
Rh+=Rhogam
O+
No risk for
development of
permanent active
immunity of Rh
antigen.
Hematocrit
34-46
38.1
No sign of anemia.
Hemoglobin
12-16
13.2
No sign of anemia.
VDRL
Non reactive
Non reactive
No sign of
syphyllis.
Rubella
Immune
Immune
Will not need
vaccination.
Urine C&S
N/A
N/A
Sickle Cell
N/A
N/A
Labs Continued
Prenatal Tests
Norms
Patient Results
Analysis
Chlamydia
Gonorrhea
Negative
Negative
No infection.
PAP test
Normal
WNL
No sign of
cancerous cells.
Triple Screen
N/A
N/A
1 Hour Glucose
Screen
70-139 mg/dl
Patient could not
tolerate
Not determined.
Labor and Delivery Data
 Vaginal delivery on 2/4/09
 Pain management via epidural
 AROM 0848. Moderate amount of light meconium
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colored amniotic fluid.
Induction with Pitocin
Stage 1 – 29 hours 45 minutes
Stage 2 – 53 minutes
Stage 3 – 6 minutes
Total time 30 hours, 44 minutes
Mother’s Postpartum Assessment
 Lung sounds clear
 Bowel sounds present at all 4 quadrants
 Breasts soft and nontender
 Abdomen firm, FH -1 below
 Lochia – moderate rubra
 Pedal pulses +2
 Negative Homan’s sign in both extremities
 Episiotomy midline and well approximated
 BP, P &R WNL
Medications During Pregnancy
 Folic Acid - Studies have shown that women who get 400
micrograms daily prior to conception and during early
pregnancy reduce the risk that their baby will be born with
a serious neural tube defect by up to 70%.
 Flintstone's Multivitamin – Taken in place of prenatal
vitamins due to GI upset. Prenatal vitamins are specially
formulated to make up for any nutritional deficiencies in
the mother's diet. While the supplements contain
numerous vitamins and minerals, their folic acid, iron, and
calcium content are especially important.
Medications During Labor
 Pitocin – Triggers and strengthens contractions to induce or move labor
along. Delivered IV starting with a small dose and gradually increased
it until contractions are strong and frequent enough for the baby to be
born.
 Lactated Ringers – Used to start and maintain the infusion of Pitocin.
This avoids risk of infusing a large dose of Pitocin as the line is begun
and provides additional fluids while the solution is kept at a low
infusion rate.
 Epidural - Block the nerve impulses from the lower spinal segments
resulting in decreased sensation in the lower half of the body.
Postpartum Lab Data
Tests
Norms
Patient Results
Analysis
WBC
5,000-10,000 mm3
25,000-30,000
mm3 PP
20.7 H
Increased
neutrophils from a
physiologic
response to stress.
RBC
4.2-5.4
2.95 L
Loss of blood,
anemia
Hgb
12-16
8.2L
Anemia
Hct
38-47
24.8L
Loss of blood,
anemia
Nutritional Assessment
 Prepregnant weight 110 lbs, 40 pounds total weight
gain during pregnancy.
 Will bottle feed and receive WIC assistance.
 Patient does the grocery shopping and cooks with no
special dietary restrictions.
 Very little physical activity.
Newborn Data
 Female
 Gestational age 40.5 weeks
 Apgar score
 1 minute=9
 5 minutes=9
 Birth weight 6 pounds 11 ounces
 19” in length
 Bottle feeding
 Mother did not attend prenatal classes
Newborn Assessment
 Temperature 97.8
 Pulse 124
 Respirations 32
 Skin pink
 Lung sounds clear
 Fontanels midline
 Sucking, grasp, Babinski, rooting reflexes present
Newborn Medications
 Vitamin K – Given prophylactically IM on the day of
birth to prevent hemorrhage which can occur because
of low prothrombin levels the first few days of life.
 Erythromycin Ophthalmic Ointment – prophylactic
treatment of opthlamia neonatorum required by law
Postpartum Medications
 Motrin-600 mg PO q8h– for mild to moderate pain.
 Tylenol 3 – 1-2 tablets PO q4h PRN for moderate pain.
 Ferrous sulfate – Iron supplement for anemia. L.S.
postpartum hemoglobin at 8.2
 TDAP – IM tetanus, diphtheria, acellular pertussis
vaccine
Care Plan for Mother
Pain R/T episiotomy AEB 6 on pain scale
 I - Assess level of pain .
 R: to determine the interventions you will use.
 I - Provide optimal pain relief with prescribed analgesics
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(Low on pain scale Motrin q6 hr, or high on pain scale
Tylenol #3 prn).
R: Relieving pain allows for promotion of activity.
I - Use of hot or cold applications.
R: Cold can reduce inflammation that causes pain and heat
(sitz bath) promotes healing in the affected area.
I - Teach pt. to use relaxation techniques.
R: The use of non-invasive pain relief measures can
enhance the therapeutic effects of pain relief medications.
Risk for infection R/T surgical incision.
 I - Assess nutritional status to provide adequate protein and caloric
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intake for healing.
R: To repair tissue, the body needs increased protein and carbohydrate
intake and adequate hydration for vascular transport of oxygen and
wastes.
I – Monitor vital signs q4h.
R: Provides a baseline that allows quick recognition of deviations in
subsequent measurements.
I – Monitor episiotomy at least q4h for redness, drainage, oozing,
hematoma, or loss of approximation.
R: Provides clinical data needed to quickly recognize the presence of
infection.
I – During postpartum period, monitor fundal height at least q4h for
48h.
R: Provides database necessary to screen for infection
Risk for ineffective coping R/T history of
depression
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I – Schedule in home follow-up to assess status of depression.
R: Helps to identify issues and can lead to problem solving.
I – Teach pt. self monitoring techniques and when to seek help.
R: Teaches them how to recognize and know when pt. needs
more intensive help.
I – Reassure pt. that depression is common post-partum.
R: Pt. with chronic mental illness must give up role of being sick
for being different.
I – Teach pt. use of cognitive therapy technique.
R: Cognitive interventions help person control his/her life with
replacing automatic negative thoughts with positive thoughts.
Risk for impaired infant attachment
related to lack of knowledge.
 I – Encourage mother to talk about her feelings regarding being a
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new parent.
R: Opens line of communication so mother will feel comfortable
and be honest about her feelings/fears .
I – Observe both parents’ interactions with infant.
R: Makes sure the bonding is appropriate, ensures infants safety.
I – Ask mother specific questions about taking care of her infant
at home.
R: Nurse can decide what exactly mother needs help or guidance
with.
I – Refer to programs in the community that help new parents.
R: New mother will have somewhere to go if she has questions or
needs help.
Nursing Diagnoses for Newborn
 Risk for infection related to umbilical cord healing.
 Acute pain related to vitamin K injection.
 Risk for impaired tissue integrity related to thin
epidermis.
 Risk for imbalanced body temperature related to less
adipose tissue for insulation with newborns.