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Case Scenario C. Taylor Ms. C. Taylor is a 30-year-old woman G5P4004 who had a prenatal course complicated by polyhydramnios and uncontrolled gestational diabetes mellitus. Medical history includes: asthma, elevated BMI, and previous smoker for 5 years but stopped when she found out she was pregnant. Her cervical ripening/induction began at 37 weeks 3 days. She has had a course of vaginal misoprostol, a Cook’s balloon, had artificial rupture of membranes (clear fluid) before starting the titrated oxytocin infusion 36 hours ago. She is now 37 weeks 6 days, 10 cm dilated, 100% effaced, and is +2 station. She has an epidural and has been pushing for 3.5 hours. 0836: Vitals sign RR 18, HR 110, Temp 99.9F, BP 110/62, Pain 3/10 intermittent pressure. What should the nurse anticipate at delivery? What risk factors put Ms. Taylor at risk for a complicated delivery? What is the nurse’s priority care at this moment? 0845: The external fetal monitor showed fetal tachycardia, recurrent late decelerations, and minimal variability. The provider attempted a forcep delivery for fetal distress. The provider delivered the head without difficulties, but then a shoulder dystocia was identified. McRoberts maneuver, suprapubic pressure, and an episiotomy was done. Baby delivered following a 90 second dystocia. NICU staff were present for delivery and resuscitated baby with tactile stimulation, bulb and deep suctioning, and positive pressure ventilation. APGARS were 4 at the 1 minute and 8 at 5 minutes. Upon examine from the NICU provider, clavicles were intact and no motor weakness in either upper extremity was noted. Some facial bruising was noted where the forceps were applied. The baby weighed 4479g (9lb 14oz). What additional risk factors does Ms. Taylor have for complications? 0915: Blood loss following delivery was 400ml. Placenta delivered, intact 30 minutes after baby delivered. Vital signs: RR 20, HR 119, Temp 99.9 F, BP 90/54, Pain is minimal. 0917 The provider performs a fundal massage. The uterus is boggy and 2/U, bleeding has increased significantly and numerous clots are being expressed. What is the priority of the nurse right now? What interventions should be done?
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