Case 5: Amelia Sung

Maternity Case 5: Amelia Sung (Core) Documentation Assignment 1. Document Amelia Sung’s admission to the labor unit, including the plan of care and appropriate referrals. 36-year-old Asian lady G2P1 (L1), Amelia Sung, was hospitalized six hours earlier in a state of active labor. She was 100% effaced, -1 station, 4 cm dilated, and fetus in vertex position, when she was admitted. At 0230, epidural anesthesia was started. At 03:30, her membranes ruptured. A step stool was in the room because of her prior history of shoulder dystocia, and we kept an eye out for turtle signs during labor. Her labor and delivery had been reported to the charge nurse. The NICU was also notified. Having extra staff in the room for delivery is vital, due to the increased
What is the difference between a'smart' and a'smart'? Document the essential events related to the time of birth, including all activities and interventions from the time of crowning until delivery of the fetus. I washed my hands and verified that I had the correct patient after introducing myself to the patient and family member. I also looked through the patient's EMR on the computer. When greeting the patient, it was obvious that she was in pain, and gave a moaning reply. After I finished the vital signs, the patient said that she was in pain and could feel a contraction coming on. At 0358 into the simulation, the fetus's head began to crown. I called the charge nurse and notified the NICU. After that, I set up the delivery table, prepared the bassinet, and evaluated the patient's IV site. In addition to checking that the step stool was in the room in case I needed to apply suprapubic pressure, I weighed and replaced the bed pads. Throughout the procedure, I soothed and assisted the patient and her family. I also gave patient education throughout the whole ordeal. Around the 0658 mark, I instructed the patient to start pushing. 1036 minutes into the VSim, the baby was delivered, and I handed the baby to the mother for skin-to-skin