April 10, 2019

Sharon Williams

Maternity Case 1: Olivia Jones

Documentation Assignments

1. Document the data from your focused antepartum assessment of

both Ms. Jones and the fetus.
 Olivia Jones, 23 year old African-American Female G1P0 at
36 weeks gestation, diaganosed with severe preeclampsia.
She is admitted to the labor and delivery unit suriveillance,
due to continued progression of preeclampsia, elevated
blood pressure, weight gain, headache, epigastric and
proteinuria

2. Write the situation-background-assessment-recommendation

(SBAR) communications you would use to update the provider on
Ms. Jones’s status at the time of her admission.

S - A woman, Olivia Jones, 36 weeks gestation, diagnosed with

severe preeclampsia. She is complaining of a headache that is not
resolved with acetaminophen and epigastric pain. She is nausea
and fatigue and she states of visual changes, tightness in the
chest. She also states, that she is quieter than normal.

From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
B – Name: Oliva Jones an African-American 23 years of age, and
she is 36 weeks gestation.

A – Reason for admission: Severe preeclampsia

 Gestation: 36 weeks, Weight: 110 kg, BP 146/92,
Temperature 99 F, HR 110, RR 12 breaths per minute
 2+ tendon reflex, +1 pitting edema on lower extremities
 Lungs sound clear
 Fetal HR 138 and fetal movement
 Oxygen: 2 L
 Medications: Magnesium sulfate, anti-hypertensive

R – Treatment Includes:
 Education, continue monintoring BP, HR, RR, oxygen, fetal
HR, and comfort measures.
 Administration of anti-hypertensive IV medication and
magnesium sulfate (side and adverse effects).
 Reduction of sensory stimulation
 Safety measures, and surveillance
 Eduation patient and support person
 Facilitating safety measures regarding patient care

From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
3. Document the teaching you would provide to the patient and her
support person prior to administering magnesium sulfate.

 Explain rationale to patient and support person with the use of

tocolytics to treat contractions and to try to prevent preterm birth
 Explain all procedures, equipment, medications, and side effects
and answer all questions
 Allow for expression of anxiety condering infant’s prematurity.
Arranging for the staff of the neonatal intensive care unit to visit
the patient to ansere questions may be helpful
 Continually update patient and family on maternal and fetal
status
 Begin patient education to increase knowledge and skills
concerning preterm labor. Patient education is individualized by
may include the following:
o Medication administration, scheduling and side effects
o Abdominal palpation and timing of contrations
o Importance of bed rest in later recumbent position
o Subtle signs or sypmptoms of preterm labor and importance
of immediately reporting symptoms
o Adequate hydration

4. Document the administration of the magnesium sulfate bolus and

the initiation of the magnesium sulfate infusion.

 Pertinet maternal and fetal assessments

 Initiation of protocols used in patient care
 All nursing and medical interventions and patient’s reponse
 Magnesium sulfate in grams per hour

From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.
  Initial and subsequent tocolytic dosages as well as time of dosage
changes
 Physician notifivation, including indication and response

5. Document your reassessment of the patient’s status after

administering magnesium sulfate.

 Assess P.R. and BP every 15 minutes first hour of infusion and

following any dosage increase every 30 minutes during the second
hour of magnesium sulfate therapy. Also, assess, P.R. and BP a
minimum of once an hour during maintenancy therapy.

From vSim for Nursing | Maternity and Pediatric. © Wolters Kluwer Health.