ChiefFog3359
Yani is a 32-year-old female who just had a 6lb., 8 oz. baby boy…
Yani is a 32-year-old female who just had a 6lb., 8 oz. baby boy eight hours prior to your shift. She had her baby with a vaginal delivery and did not have vaginal tears or require an episiotomy. She has a saline lock in her right hand to keep the vein open. She is accompanied by her husband with her baby at the bedside. You have just started your night shift and are preparing to do her vital signs. You do her vital signs and note they are the following: Temp: 36, BP: 70/50, Pulse: 130, RR: 24, Pulse Ox: 88% room air. You ask she tells you this. She continues further by saying “goodness, I am sweating so much, I am so embarrassed, can you help me change.”
Yani’s fundus is a normal finding. Yani states her dizziness has worsened. You recheck her vital signs and you get the following: T-36, BP: 60/40, Pulse: 65, RR: 10, Pulse Ox: 85%, and lochia rubra with massive clots.
You initiate a conversation with her and her response is strange; she appears quite confused. Suddenly, she closes her eyes and is unresponsive with a pulse.
1. Using SBAR demonstrate what you would say to the doctor based on how Yani is presenting.
2. What two orders would you anticipate the doctor to do STAT and if he/she did not state would you ensure that are ordered?
3. After Yani’s transfusion and hours later you check on her and she is looking frustrated and upset. She expresses wanting to go home to her newborn and questions you as to whether or not she is going to die. As the student pre-grad nurse, how do you handle the situation?
4. Its fundus is a normal finding. Yani states her dizziness has worsened. You check her vital signs, and you get the following: T36, BP: 60/40, Pulse: 65, RR: 10, Pulse Ox: 85% and lochia rubra with massive cloths.
– You initiate a conversation with her and her response is strange; she appears quite confused. Suddenly, she closes her eyes and is unresponsive with a pulse. Explain what has happened to Yani based on the findings and state your next steps
5. The doctor is on the phone with. Describe the acronym SBAR
6. Yani continues to express being embarrassed by her soaked gown, she asks you “why am I sweating so much, is this normal I have never sweated like this in my life?” What is your response to this and describe what you would tell her and her husband?
7. Based on Yani’s VS and how she represents what is the number of one priority postpartum assessment that needs to be completed at this time and what is the rationale?
8. For each vital sign noted what is the normal range for an adult female and state whether if Yani is overall stable or not.
9. Yani has lost a lot of blood and her blood work results showed her hemoglobin to be 23g/L, which is abnormally low. The physician has been informed and has ordered one unit of packed red blood cells to be administered STAT.
Yani’s pre-transfusion vitals are T-36.7 C, P-68, R-18, BP 126/84
15 minutes after the transfusion starts her vitals are as follows T-38 C, P110, R-24, BP 90/55
What is you next step and why?
