NCM 109 Case # 3

 You are the nurse assigned

in the OB ward of Fabella
Memorial Hospital from 6-
2PM shift. Suddenly, the
phone rings “ Admission
from ER, a 23 year old
female G5P4. ” Hence , you
prepared the room for
admission
ENDORSEMENT FROM THE E.R NURSE

“ENDORSING THIS 30 YEAR OLD FEMALE G5P4, 33 WEEKS AOG”

CHIEF COMPLAINT: “ I AM HAVING FREQUENT CONTRACTIONS

SINCE THIS MORNING, ITS NOW 12 NN AND I CAN FEEL THAT IT IS
GETTING MORE STRONGER AND MORE FREQUENT”. The patient
also verbalized: “ My husband and I also had sex last night”

The ER nurse also endorsed patient’s OB scoring as

G5P4 T=2 P=2 A=0 L=4
Internal Exam
Result done in ER
cervix=2-3cm
dilated
effacement=not yet
effaced
BOW (+)
no bleeding noted
Doctor’s Order:Upon admission

 1.Vital signs monitoring hourly esp cardiac rate

 2.Monitor and record uterine contractions
 3.Hook patient to a fetal monitor
 2.IVF D5W1L and incorporate terbutaline sulfate @ 10-15 microdrip/min
 3.CBC w/blood typing=blood extracted, results for follow up
 4.Routine Urinalysis=Urine specimen sent to lab and for urine culture
 5.Medications: Give Betamethasone 12 mg IM for 2 doses @ 24 hours apart
 6. CBR w/o BRP’s
 7. Avoid heavy meal but keep patient hydrated at all times
 8. Notify Neonatal Intensive Care Unit
Laboratory Results:

Hematology Reference Values Patient’s Results

/Interpretation
Hgb Female:12-16g/dl 12g/dl
Hct Female:36-46% 38%
WBC Adult:5,000-10,000 7,000
RBC Female:4.0-5.0 4.5
Platelet 150,000-400,000 200,000
Hematocrit 36-46% 38%
Blood Type B+
Laboratory Result

URINALYSIS Patient’s Result

COLOR Slightly Turbid
pH 6.0
Specific Gravity 1.0
Protein negative
Glucose negative
Pus cells 15-20
Red cells 5-10
Mucus Threads moderate
Bacteria Few
Patient hook to fetal monitor

 RESULT:
Contractions @
10-15 minutes
interval
 FHT=130
beats/minute
 mild to moderate
in intensity