Clinical Case Studies

Case Study 1: Newborn AssessmentYou assist in the vaginal delivery of a live baby without an episiotomy. You dry and stimulate the infant to breathe, re-move the wet blanket and replace it with a dry one, and then place the infant skin to skin on the mother’s chest. You as-sess the need for infant resuscitation. The baby has a lusty cry spontaneously less than 30 seconds after birth. You pal-pate the cord obtaining a heart rate of 120 and observe that the baby’s chest and face are pink and the legs and arms are flexed with an open fist.

1. Explain the changes that must occur in the infant’s cardiopulmonary system at birth.a. lungs inflate as amniotic fluid drainsb. with first breath, BP decreases in pulmonary artery => ductus arteriosus begins to

closec. increased blood flow to left side of heart causes foramen oval to close because of

the pressure against lop of the structured. umbilical vein and arteries and ductus venosus no longer receiving blood from pla-

centa, blood within them clots and the vessels atrophy over the next few weeks 2. What criteria do you look for when you assess for adequate cardiopulmonary adaptation at

birth?a. Vigorous/ lusty cryb. Heart rate greater than 100bpmc. Pink color

3. What are the 4 methods that an infant can lose heat, thereby increasing the chance of cold stress? What interventions described above assisted in preventing heat loss?

a. Conduction, convection, evaporation, radiationb. Dry newborn immediately after birth; wrap baby in warmed blankets; avoid placing

newborn in draft or near air vents; delay initial bath until baby’s temp has stabilized; avoid placing cribs near cold outer walls

4. Discuss nursing actions that can decrease the probability of high bilirubin levels in the newborn.

a. Maintain skin temp at 36.5 C or aboveb. Monitor stool for amount and characteristicsc. Encourage early feelings

Case Study 2: Phototherapy A 5 lb baby was delivered at 38 weeks by primary cesarean section for fetal distress. APGARs were 7 at 1 minute and 9 at 5 minutes. The infant is suctioned, given free flow O2 and is admitted to the nursery and does well. You are caring for the baby at 36 hours old. You review the records and note that baby’s blood type is A+ and his mother is O+. The mother wants to breastfeed. Your assessment on the baby reveals a unilateral cephalhematoma and lethargy. You blanch the skin over the sternum and observe a yellow discoloration of the skin. Lab tests reveal a bilirubin level of 12mg/dL, HCT 55%, a mildly positive direct Coombs’ test and a positive indirect Coombs’ test. The baby is diagnosed with hyperbilirubinemia and phototherapy is ordered.

1. List at least 3 issues from the above data that could be the reason for hyperbilirubinemia.a. Cephalhematoma, different blood types, positive direct Coomb’s test

2. How would you explain the purpose of phototherapy to the mother?a. To eliminate bilirubin in blood

3. Describe the care that the mother can give to the newborn, including what she should be looking for in her care.

a. Feeding child every 2-3 hours

Case Study 3: Post-Partum CareA 25 year old G3 P3 is 2 hours past a forceps vaginal delivery with a right medio-lateral episiotomy of a live 8-pound baby boy. Her VS are: 118/70, T 98’, P 76, RR 14. The fundus is 1 finger above the umbilicus and slightly to the right. Her episiotomy is slightly ecchymotic and well approximated without edema or discharge. Ice has been applied to the episiotomy for the last 20 minutes. Lochia rubra is present and a pad was saturated in 90 minutes. Janet has an IV of LR with 10 units of Pitocin at 100cc/hr in her lower left arm and is complaining of “moderate” abdominal cramping. She tells you that she is very tired and requests some pain medication so that she can sleep for a while.

1. What nursing assessment is of immediate concern?a. Uterus above umbilicus and deviated to side might indicate full bladder; offer bath-

room time for the woman 2. Discuss care of her episiotomy and perineum.

a. Inspect redness, edema, ecchymosis, discharge, and approximation of wound b. Ice packs first 24 hours; sitz baths; kegals; inspect for hemorrhoids; encourage: am-

bulation, fluids, high fiber, witch hazel, stool softeners3. What other self-care and safety measures would you advise at this time?

a. Lochia rubra should not have large clotsb. Let nurse know if discharge is excessive with foul smellc. advise to call for help if needing to get off bed as she could feel dizzy

4. Discuss post partum occurrences that may cause special concern for the mother.a. night sweats might occur due to body attempting to eliminate excess fluidb. pains are common due to uterine contraction

5. The patient expressed concern about her episiotomy healing. What information can you offer?

a. provide location of episiotomy and explain that sutures will not have to be removed but will dissolve slowly

b. when sutures dissolve over next few weeks, tissues will be strong and edges wont be separated

Case Study 4: Labor & Delivery

Mrs. M. is a 27-y/o G 3, P 2, who was admitted at term at 6:30 p.m. She stated that she had been having contractions at 7 to 10 minute intervals since 4 p.m. They lasted 30 seconds. She also stated that she had been having "a lot of false labor" and hoped that this was "the real thing". Her membranes were intact. Mrs. M.'s temperature, pulse and respirations were normal and her blood pressure was 124/80. The fetal monitor revealed a fetal baseline of 135, moderate variability, 15x15 accelerations, no decelerations. The nurse examined Mrs. M. and found that the baby's head was 4/80/+1. She reported her findings to the doctor and he or-dered Demerol 50 mg. with Phenergan 25 mg. to be given intravenously q2h PRN.

1. Do you think Mrs. M. is in false labor? Give reasons for your answer.a. No, because she stated that she had been having “a lot of false labor” so she knew

how they felt and changes to the false labor (increase in duration and intensity) means it is a true labor

2. As Mrs. M is getting into bed, her membranes ruptured. What is the first thing that you do after this occurs? Why?

a. assess FHR to detect changes associated with prolapse of umbilical cord 3. After her membranes ruptured, her contractions began coming every 4 minutes and last

45-55 seconds. There were moderate in intensity. Why is it important for her to relax dur-ing her contractions? How can you help her?

a. Oxytocin works best when woman feels calm, safe and relaxed; reduces anxiety and pain/intensity of contraction

b. By using visual imagery4. When do you think Mrs. M should be given the medication ordered by the doctor? What

safety measures should be taken at the time the medication is given? What observations should be made after it is given and why? What observations would you report to the doc-tor?

a. During first stage of laborb. Pt would be a fall risk after given the meds; bed at lowest position and call light

within reachc. FHR for signs of late decelerations; urinary retention is anticipated;d. respiratory depression, seizures, cardio vascular collapse, cardiac arrest, bron-

choconstriction, agranulocytosis 5. How would you know that Mrs. M has entered transition phase?

a. she “hoped that this was ‘the real’ thing”6. A vaginal exam reveals that Mrs. M is 10/100/+2. What should be the nursing interven-

tions at this time?a. use breathing techniques or pattern-paced breathing; restb. maternal blood pressure, pulse and respirations taken every 30 minutes and FHR

every 30 minutes

Case Study 5: Fetal Monitoring

Identify the type of deceleration, its cause, and nursing interventions for each:

Strip A: Strip B:

Strip C:

A: variable decelerations-cause: vagus nerve firing resulting from umbilical cord compression-interventions: change mom’s position, administer O2

B: late decelerations -cause: uteroplacental insufficiency and decreased blood flow and/or O2 transfer to fetus through intervillous

space during contractions -interventions: turn mom onto her side, administer O2, maintain IV access

C: early decelerations -cause: vagal nerve stimulation caused by fetal head compression that occurs during UCs -interventions: continue to monitor and document process of labor