Maternal Assessment Critical Question & Answer Guide (With Explanation)
Understanding this question requires applying core subject principles.
What This Question Is About
This question relates to maternal assessment critical and requires a structured academic response.
How to Approach This Question
Break the problem into smaller parts and analyze each logically.
Key Explanation
This topic involves maternal assessment critical. A strong answer should include explanation, application, and examples.
Original Question
Maternal Assessment Critical Thinking Map Admit Date: 03 – 24 – 2025 Age: 24 Sex:f Allergies: no know allergies Admit Dx: Abdominal pain / C-section Code Status: Pertinent Secondary Medical Dx: Allergies: Activity: ADLIB Diet: regular Status on Day of Care (postpartum day one, C-section post-op day 2 etc..). What are the expected findings for this client? Labor/Delivery Summary G___2__ T__1 P__1__ A_ 0_ L_2 EDC 3-31-2025 Type of delivery C-section Date of delivery 03-24-2025_@ __________ Length of Labor N/A Length of Time ROM_ N/A AROM/SROM N/A Color of Amniotic Fluid: _clear__ EBL__869_mL Newborn Gest Age By Dates:​_39.0__By Gest Age Exam: _______ SGA—AGA—LGA APGAR Score: 1 Min.:___8__ 5 Min.: __9___ WT _4070_____Gms____9__Lbs.__0___Oz Length__52 Breast or Bottle-yes Formula Type_similac ________ L&D meds _____________________________ Type of anesthesia: Local Epidural Spinal- yes General None Antibiotics in labor (Y or N) #doses________ Time of 1st dose__________ Fetal monitoring issues/L&D complications: Special Request/Birth Plan Wishes: Vital Signs 0800 1200 1600 T 36.9 HR 93 RR 16 BP 143/75 SpO2 95 Pain Characteristic Location Intensity Duration Alleviate Aggravate Highlight the data that is associated with the client’s priority concerns. In the event an assessment area below is not appropriate simply put NA in the box. Neuro: A & O x ________ / Confused: _________________________ PERRLA / Cooperative / Clear speech / Other: ___________________________________________ Activity: Up ad lib / 1 or 2 person assist / Bed rest / BSC / Walker / Cane / Bed Alarm / Fall Risk / Neuro ✓ Cardiac: Pink / Pale / Warm / Cool / Dry / Diaphoretic / Other_____________ Cap Refill time: ________ S1 / S2 / S3 / S4 / Tele / Rhythm: ________________ Auscultation: Reg / Irreg: Murmur: ___________________ Edema: None / Gen / R L / Bilateral Trace 1+ 2+ 3+ Pitting / Non-pitting Location____________ Pulses: Radial: Strong / Weak / Not palpated/ Doppler / equal / _____ Pedal: Radial pulses: Strong / Weak / Not palpated/ Doppler / equal / _____ Respiratory: O2 @ __________L NC / Mask / NRB / Room air / Other ____________ FIO2: ________ L: ________ Breath Sounds: L: Clear / Diminished / Wheezing / Crackles / Coarse R: Clear / Diminished / Wheezing / Crackles / Coarse Increased WOB: Yes / No Cough: Yes / No Productive / Non-productive / NA Treatments: IS / SVN / Suction: Breast: Soft/Filling/Engorged/Leaking _____________ Does the client have a bra on? ___________ Latch score _______ Is the client pumping? ___________ Nipples: Tender/Cracked/Bleeding/Intact ________ Is the client using nipple shield? _____ Uterus: Tone: Firm/Soft/Boggy____________ Level of involution? ___________ Location: Midline/Deviated to L/Deviated to R_______ Any uterine tenderness? _____ Bowel: BS: Hypo / Active / Hyper Assess: Nausea / Vomiting: ______ Last BM: _________ Consistency/ Color: _________________ Abd: Soft / Tense / Firm / Non tender / Tender / Distended________ Hemorrhoids? ________ Bladder: Voiding / Foley / Incontinence / Anuria/ Clear / Cloudy / Yellow / Amber / Bloody / Other: ______________ BR / Urinal / BSC / Bedpan / External Cath Dysuria or Urgency? _____ Does the client feel she is able to empty her bladder? ________ Has the client voided since delivery or the removal of catheter? _________ Lochia: Type: Rubra/Serosa/Alba_____________ Amount: Scant/Light/ Moderate/Heavy _______ Odor: Fleshy/Foul _______________ Episiotomy: Episiotomy or Laceration: Type________ Assess per REEDA: Any bruising or edema? Lower Extremities: Post-anesthesia assessment: Sensation/Movement & Strength of legs___________________________ Upper Strength _____/5 in RUE / RLE Lower Strength _____/5 in LUE / LLE Weak/ Numb / Decreased ROM / Edema/Redness/warmth in lower extremities? ______________________________________ Reflexes__________Clonus________ Emotional Bonding & Caretaking behaviors noted: ______________________________ Family support present ________________________ Cultural needs met? ________________ Mom& baby ID bands match____ Psychosocial findings: _________________________________ Skin/Wounds Assess epidural/spinal site per REEDA Description: Location: N/A IV: Site: _____ Gauge: _____ Saline-locked: Yes / No Maintenance Fluid: _____________ Rate: ________ Date placed: _____ S&S of infiltration or phlebitis: Yes / No Action: ______ Precautions: Fall / Bleed / Contact / Airborne / Droplet / Protective Complete Lab section if appropriate. Highlight abnormal (high or low). In the event an assessment area below is not appropriate simply put NA in the box. Lab Result Significance to nursing care? Blood Type A+ Rh Factor Is Rhogam Warranted? Yes WBC’s (4500 – 11, 000/mm3) 12.3 Hgb (12-16 g/dL) 13.3 Hct (42-54 %) 33.4 Platelets (150, 000 – 400, 000/mm3) 231 VDRL status N/A GBS status N/A Rubella status 1 m Varicella N/A Blood Glucose 1. ___112___ 2. _____ 3. ______ 4. ______ 1. _____ 2. _____ 3. _____ 4. _____ Other Diagnostic Tests: Summary (in this box summarize likely reason for abnormal, high, or low): Why might these lab results be present with THIS pt.? Pathophysiology (In your own words) of any secondary diagnosis: Complications/Potential Complications (Risk Reduction): Psychosocial Concerns (Psychosocial Integrity): Recognizing Cues: Assessment findings that warrant further investigation (VS/Subj./Obj./Labs/Diagnostics/Risk Factors/Psychosocial): 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. **May have more than 10 cues Prioritize Hypotheses: These are your Nursing Problem Statements. What do you think is the highest priority? What is it related to? Is it an actual problem or a risk problem? Take Action: These are your interventions. What will you do to help improve your client’s condition or prevent further deterioration? (Basic care & Comfort, Safety and infection control, Pharmacological therapies, Education, Health promotion, and management of care): Generate Solutions: Planning and goal setting. What do you want as an outcome for your client? Goals should be SMART goals. Analyze Cues: What do you think might be going on with the client? What does it mean? This is where you analyze the data you collected: Evaluate Outcomes: Did your actions result in the desired outcome for your client? Medication Name (Generic) and Drug class Patient’s Dose, Route, and Frequency Why is patientreceiving this medication? Nursing considerations (labs, assessment, etc.) Lactation Considerations Side effects and Major adverse effects Patient Teaching Oxytocin 500 lm Q1 1H55M IV Ondanserton HCL 4mg Q8H PO Measles/mumps 0.5 lm once PRN Sub Magnesium sulfate 30 ml Q24H PRN PO Oxycodonel/ Acetaminophen 1 tab anestheisa IV Nalaxone 0.1 mg anesthesia IV Rhogam 1500 unit once PRN, IM Hydrocodone I tab Q4H PRN PO Ibuprofen 800 mg Q8H PRN PO Prenatal/ mutivitamin folic acid/iron 1 tab daily PO Patient Teaching (Health Promotion, Safety and Infection Control, and Management of Care): Summary Report to Healthcare Provider (SBAR Format): S- B- A- R- Please answer all the line and boxes thank you.
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