Question 1. ASSESSMENT Current History: Nancy Preg is a 27-y/o gravida 3,… 1. A

Question 1. ASSESSMENT Current History: Nancy Preg is a 27-y/o gravida 3,… 1. ASSESSMENTCurrent History:Nancy Preg is a 27-y/o gravida 3, term 2, preterm 0, abortion 0, para 2, Caucasian female who was admitted at 40 weeks gestation at6:30 a.m. for labor. She is GBS positive, blood type O negative, Rubella immune, Hep B negative, STI negative, AB screen negative,HIV negative. Her husband is at her bedside and will be her support person throughout labor. This is his first child. She stated that shehad been having regular, painful contractions since 4 p.m. They last 60 seconds. She also stated that she had been having “a lot offalse labor” and hoped this baby would come soon. Her amniotic membranes are intact. Mrs. Preg’s vital signs were the following:97.9 deg F, 86, 18, and 124/76. The fetal heart tones were 134 and moderate variability. The nurse examined Mrs. Preg and found thatthe baby’s head was at -2 station, and the cervix was 3 cm. dilated and 80 percent effaced. She reported her findings to the doctor andhe ordered routine admission. Patient has NKDA, weighs 183 lbs currently (weight 154 lbs on initial prenatal visit).Social/Cultural History:With the current pregnancy, Mrs. Preg had been admitted to the hospital at 30 weeks gestation in pre-term labor. She was treated withTerbutaline (Brethine) 0.25 mg SQ X 3 doses, Betamethasone (Celestone) 12 mg IM X 2 doses (24 hours apart), Magnesium Sulfate 4gm bolus IV and then 2 gm/hr X 24 hours, Ampicillin (Ampicin) 500 mg IV every 6 hours, Nalbuphine (Nubain) 10 mg IV every 6hours prn (patient had 3 doses), Phenergan 25 mg IM for nausea (she had 2 doses), Nifedipine (Procardia) 10 mg PO TID (patient wasdischarged home on this med. and she stopped taking this at 36 weeks gestation). She had RhoGAM 300 mcg IM at 26 weeksgestation. There are no other social or cultural issues noted.Past Labor & Delivery History: Induced at 40 weeks using Dinoprostone (Cervidil) for her first labor. Her first labor lasted 22 hoursand she was also placed on Pitocin (Oxytocin) and her membranes were artificially ruptured by the physician. She also had an epidural with Duramorph (Morphine). She had a spontaneous vaginal delivery (SVD) of a healthy female weighing 7 lbs. 8 oz. (childis now 7 yrs old). Her second labor lasted 6 hours and her only medication used was Misoprostol (Cytotec) 3 doses at 0.25 mcg/dose.She did not have time for an epidural and had a natural SVD of a healthy male weighing 8 lbs. 2 oz. (child is now 3 yrs old). Shestates she did have a postpartum hemorrhage due to a retained placental fragment that required her to undergo a D&C at 18 hrs afterher delivery. She experienced no further complications.Current Medications:• Docusate Sodium (Colace) 100 mg PO daily• Prenatal Vitamins-Folic acid 1 tab PO daily• Simethicone (Gas-X) 40 mg PO after meals and at bedtime• Acetaminophen (Tylenol) 325 mg PO every 4 hrs as needed• Percocet (Oxycodone) 5/325 mg PO every 4 hours as needed for pain (patient has chronic back pain and has taken 1 tab every4 hrs since 32 weeks gestation).What data from the history assessment is IMPORTANT for you as the nurse?Data from Current Problem: Why is this important?Data from Social/Cultural History: Why is this important?Data from Past L&D History: Why is this important Health Science Science Nursing NSG 312 Share QuestionEmailCopy link Comments (0)

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