Bulacan State University

Malolos, Bulacan
College of Nursing

Case Scenario

Case Scenario 1 Postpartal Clientele

Mrs. K. is a 32 y/o G3P2 (2002). Pregnancy Uterine 39 weeks AOG came to OB ER at 9:00 a.m with the chief
complaint of persistent uterine contractions. She stated that she was having 30-35 seconds contractions at 20
minutes interval since 7 a.m. “Naninigas ang tiyan ko kada 20 minuto tumatagal ng mga 30-35 segundo.” Vital signs
were taken and noted afebrile with the temperature of 36.7 degrees celsius, pulse rate of 85 bpm, respiratory rate of
20 bpm and BP of 122/80 mmHg. Her bag of water was still intact. FHT was 139 -140 bpm. The OB doctor examined Mrs.
K. and found that the baby’s head was at +1 station, the cervix was 5 cm dilated and 80 percent effaced. The physician
ordered Demerol 50 mg IV PRN. An intravenous line was placed on Mrs. K’s right hand metacarpal vein and was
admitted in Labor and Delivery Suite at 9:15 a.m.

At 10 a.m., Mrs. K. has been experiencing contractions every 5 minutes lasting for about 60 seconds. Cervical
dilatation on examination is 7 cms. The nurse observed rupture of patients’ membrane. Mrs. K. was transferred to
delivery table and perineal care was done. The nurse advised the patient to start breathing exercises and relaxation
techniques.

At 11 a.m. Her cervix was fully dilated at 10 cms. The doctor administered lidocaine injection into the pudendal
canal and midline episiotomy was made. At 11:15 a.m, Mrs. K gave birth to a live baby boy in 3,300 grams or (7.26 lbs.)
with the most favorable fetal position for birth. EINC with “UnangYakap” (first embrace) was rendered for early
breastfeeding initiation. Name tags were attached to both mother and child. At 11:30 a.m, the placenta separated

Level II 2nd Semester SY 2020-2021

completely from the wall of the uterus. Oxytocin 10 units was administered by the nurse through IM as ordered.
Suturing was made on the episiotomy.

As a nurse assisting the postpartal client and her newborn baby, prepare one (1) nursing care plan that best
cater the healthcare needs of the client and select all medication mentioned in the given situation to compose a drug
study.

Prepared by:

CARMINA O. FABONAN RN
Level 2-Clinical Instructor