32 year old Hannah H. delivered ahealthy baby girl by scheduled cesarean section at 39weeksgestation lastnight at 11:52pm. This is her 4thbaby. Shedelivered her 8 yearold at 35weeksgestation, her6 year old at 37 weeksgestation, andher 3 year old at 40 weeks gestation. She also had 2 spontaneousabortions before this pregnancy.
1.List the GTPAL. G__T__P__A__L__.
Hannah has afoley catheter and IV fluids running through a peripheral IV in herright forearm. Her pain scoreis a 5/10 at the incision site. Hannah states that a pain score of3/10 would be tolerable for her.
The nurseperforms her BUBBLE assessment and notes breasts are normal, uterusis boggy,midline, and U/U with moderatebleeding that continues to trickle.
2.Whatis your priority at this time?
Afterinterventions the bleeding has returned tonormal. The nursewill continue to monitor.
3.What additional information is needed on this patient in order toprovide priority nursing care for Hannah?
Hannah’s bloodloss after delivery was 587ml. The nurse knows that she shouldcontinue to weigh the chucks pads to keep track of any additionalblood loss.
The nursefinds Hannah’s prenatal labs. They are as follows:
Blood type: B
Rh Factor: positive
Antibody Screen: Negative
RPR/VDRL: Negative
Rubella: Non-Immune
HIV: Negative
HBsAg: Negative
Hgb(12-16preg):12
Hct(33-39%preg):34%
Platelets(150-400:184
1.Areany of the prenatal lab results significant?
Current vitalsigns:
BP:110/68
Pulse:66
Respirations:18
Temp:97.6
Pain score 1hour after receiving 600mg Ibuprofen: 5/10
2.Is there anything significant about her vital signs?
3.Formulate priority nursing diagnoses based on the information youhave.
4. 3 priority nursing dx
