Andrea, a G1Po, and her husband have been trying to conceive for 3 years.  They are both school teachers and have a lot of family support.  Their families all live in the same small town and they get together frequently.  She states she did the home pregnancy test and “it was positive”.   She goes on, “I can’t believe I’m pregnant, I feel so good!”  Andrea’s last menstrual period was 5 weeks ago.  Her only complaint is slight breast tenderness and mild fatigue.  Pelvic exam reveals the uterus to be enlarged to about 5-6 weeks size.

Two weeks later Andrea comes to the clinic in tears, “I’m spotting”.  The breast tenderness and fatigue are worse and she now has morning nausea.  Upon speculum exam, it is noted that the cervix is closed.  The Chadwick’s sign is + and the uterus is about 6-8 weeks size.  There is a small amount of dark blood seen at the cervical os.  No fetal heart tones (FHT) are heard with the Doppler at this time.

  1. If today is March 10 and her LMP was January 1, what is her due date?  How many weeks pregnant is she?
  2. What is Chadwick’s sign?
  3. What are the underlying causes of the breast tenderness, nausea and fatigue?  What is the significance of those symptoms disappearing?
  4. List some questions you can ask that are related to the spotting.
  5. What could be the reason for the spotting?
  6. Nausea and vomiting are common in pregnancy, when would they be considered abnormal?  What advice can you, the nurse, give Andrea to relive her nausea and vomiting?

After an ultrasound to confirm an intrauterine viable pregnancy, a speculum exam was performed to determine the condition of the cervix and the source of the bleeding; Andrea was reassured and sent home.

  1. What advice should be given to Andrea regarding the bleeding and her activities?

Andrea’s pregnancy has proceeded normally since the spotting episode and she is now 38 weeks.  She has gained a total of 26 lbs.  Her BP at the last visit was 110/68.  The Baby’s growth has been right on schedule with a fundal height of 36 cms 2 weeks ago.  She has read everything she could get her hands on about labor and delivery.  She plans to return to work soon after the baby’s birth and will formula feed her baby.

She presents at the triage area after having contractions all night.  Her contractions are 2-3 minutes apart lasting 60 seconds and though prepared, she is having a hard time getting through the contractions.  The cervical exam reveals she is 6 cm dilated, 100% effaced, +1 station, and her membranes are intact.

She is admitted to the unit and placed on the external fetal monitor.  The FHTs are 130-140 with no accelerations and minimal long term variability.

  1. What stage and phase of labor is Andrea in?
  2. What is the significance of this monitor strip?

A decision was made to insert a fetal scalp electrode to do internal monitoring so an amniotomy was accomplished.  The fluid was meconium stained.  The strip showed minimal variability baseline 130s.

After 30 minutes it is noted that the heart rate suddenly decelerates to 100 BPM, then quickly rises to 150 BPM for 15 seconds and then returns to the baseline 130s.  This happens 3 times in 10 minutes.

  1. What is the possible cause of this?
  2. What nursing actions are necessary?

The doctor orders an anmiofusion.

  1. What is the procedure and why has he ordered it?

The variable decelerations continue and are becoming deeper, longer and more ominous even though the patient is on O2 (full blastJ) on her side with the amniofusion running.

Andrea is then taken to the OR for a C-Section birth of a 7 ½ lb baby girl with Apgar scores of 8-10.  The cause of the variable deceleration was the baby’s entanglement in the cord.

  1. Because this baby was a C-Section, what complications should you look for?
  2. Because Andrea had a C-Section, what would be impacted as far as her post partum care?

Since Andrea’s preference is to formula feed, what measures need to be taken in order to prevent the milk from coming in and what instructions need to be given to her to care for her breasts when she goes home?

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