Question

A 22-year-old woman presents to the hospital at 34 weeks gestation. She is G1P1. It was an uncomplicated pregnancy until 12 hours prior to admission, she experienced escape of fluid from the vagina, non-foul smelling.

She developed fever (38.2 degrees centigrade) around 6 hours prior to admission and she currently experiencing mild to moderate uterine contractions. She was started on antimicrobial treatment per IV. FHR is 118 bpm, RR=28   PR=90 BP= 110/70

2. Identify at least 2 -3 actual nursing problems (except for risk for infection) affecting the client and her baby
3. Prepare an NCP following the format:

3.1. Subjective/objective data

3.2. Nursing Diagnosis

3.3 Rationale (should indicate book sources or references)

3.4 Goals/ objectives

3.5 Nursing interventions

3.6. Scientific rationale for the interventions

3.7. Evaluation criteria

Answer 1

THREE NURSING PROBLEMS AFFECTING CLIENT AND BABY

· Abruption of placenta where placenta separates from the uterine wall prematurely, usually after the 20th week of gestation, producing haemorrhage

· Dystocia refers to difficulty in labour which is because of the uterine dysfunction, fatal malpresentation, or pelvic abnormality

· Preterm labour also called premature labour. It is the rhythmic uterine contraction leading to cervical changes after fatal viability but before fatal maturity, this usually occurs in the 20 tie and 37 the weeks of gestation

NURSING CARE PLAN FOR MATERNAL AND CHILD CARE

3.2. Nursing diagnosis

· PIH

· Identify foetal and presentation

· Rule out CPD in prime gravida

· Investigation using CBC

· Urine

· RBS

· HBS Ag

· Ultrasound

3.4 goals/ objectives

· To screen high risk cases

· Detect early complications

· Continued medical surveillance

· Maternal education about the physiology of pregnancy

· To ensure a normal pregnancy with delivery of healthy baby from a healthy mother

3.5 nursing interventions

· Brushing tooth soon after eating

· Eating small frequent meals

· Increase vegetarian food

· Minimising urinary frequency

· Avoiding constipation

· Maintaining tissue integrity

· Eat slowly

· Reducing anxiety

· Reducing pain by exercises

· Instruction to vitamin e cream to breast and nipple area

· Instruct to wear fitted supportive brassier

· Minimalizing morning sickness by,

3.6. Scientific rationale for the interventions

· These indicators of labour progress may identify a contributing cause of prolonged labour. For example, breech presentation is not as effective a wedge for cervical dilation as is vertex presentation.

· Excess maternal exhaustion contributes to secondary dysfunction, or may be the result of prolonged labour/false labour

· A rigid or unripe cervix will not dilate, impending fatal descent/labour progress. Development of amnionitis is directly related to length of labour, so that delivery should occur within 24 hr after rupture of membranes.

· Bowel fullness may hinder uterine activity and interfere with the fatal descent.

3.7. Evaluation criteria

· Hyper metabolic state

· Vomiting

· Restricted oral intake