You are a nurse working in labor and delivery unit at a Walden Community Hospital. A Patient is sent to you from the physician’s office for a non-stress test to determine fetal well-being.
The Patient
The patient is a G3P2 at 38 weeks with a prenatal history of gestational diabetes, which is well managed with diet. The patient is scheduled for an induction of labor at 39 weeks.
You place the patient in a bed and attach the fetal monitor to the patient.
You complete a nursing assessment. The patient reports that she feels well: there is no evidence of facial or pedal edema, reflexes are 2 bilaterally. Patient denies blurred vision, headache, or epigastric pain. A urine sample is collected and reveals negative protein. The fetus is active with a fetal heart rate of 140-145 BPM with accelerations of the heart rate with fetal movement. A set of vital signs are obtained – the blood pressure is taken using the automated B/P, a built-in component of the fetal monitor. The patient’s blood pressure is noted to be 180/120, P 72, RR 16. A repeat blood pressure is obtained using the same method of measurement and noted to be 160/116.
CONTINUE
What should you do?
1:Take blood pressure for 3rd time using the automated B/P, a built-in to the fetal monitor
2:Call the physician
3: Retake the blood pressure using a manual blood pressure cuff
ANSWER: 3 You take the patient’s blood pressure with a manual machine. It shows 116/68. You realize the automated B/P a built-in component of the fetal monitor was not functioning properly! You are happy to know you took the manual reading, which helped ensure patient safety by avoiding unnecessary or dangerous treatments.
Go back and choose a different option to see what would have happened if you had made a different choice!
You notify physician of assessment findings and blood pressure readings
He adds the following orders: Admit patient outpatient status; Labs: CBC Liver function and Uric Acid, Urinalysis; Start LR at 125/hour
Orders (cont’d)
Start Magnesium sulphate at 4gm loading dose over 20 minutes and then 2gms hour; IV Blood pressure every 15 minutes for one hour then every 30 minutes; Insert foley catheter with hourly output; Strict I