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Cindy, a 17 year-old G1P0 is admitted to the labor and delivery unit for an induction at 38 weeks gestation. She was diagnosed with preeclampsia at 34 weeks gestation. She has been on strict bed rest for the past 4 weeks. 

 

She has been doing daily fetal kick counts and had a BPP done 2 days ago which was normal. She has been placed on an external fetal monitor and FHT’s are 125-135 with accelerations noted. The external contraction monitor shows no contractions and Cindy denies feeling any contractions. A vaginal exam is done and she is 2 cm dilated, 75% effaced and the fetus is at a 0 station. 

 

An IV of LR has been started in her left forearm and is running at 75ml/hr. The physician has prescribed MgSO4 and has ordered initial admission labs: CBC, Type and Cross and a Liver Profile now and a MgSO4 level to be drawn in 2 hours. The time is now 0800. 

 

1. What is the normal loading dose for MgSO4? What assessments should the nurse perform related to the administration of MgSO4 and potential side effects? Why is Cindy receiving this medication? 

 

2. The loading dose has been administered and was complete at 0830. The physician has ordered the maintenance dose to be 2 GM/hour. The MgSO4 has arrived from pharmacy mixed as 40Gm in 1000cc of LR. Calculate the hourly rate in ml/hour. 3. It is 0845 and you have placed a foley catheter with a urimeter attached per physician’s orders and are to perform an hourly assessment of intake and output. Upon placing the foley catheter you receive a return of 150 mls of urine. 

 

The physician has also ordered a pitocin drip to be administered to begin the induction of labor. The order is to administer the pitocin at 2 milliunits per minute and increase by 2 milliunits every 30 minutes until regular, moderate contractions are achieved. 

a. You mix 20 units of pitocin in 1000 milliliterss of LR. How many milliliters per hour will you set the IV pump for to achieve the rate of 2 milliunits per minute? 

4. What side effects should the nurse monitor for related to the administration of pitocin? 

 

5. The pitocin drip was started at 0900. The time is now 1100. The pitocin drip is currently set at 8 milliunits per minute. Cindy is having contractions every 3 minutes, lasting 60 seconds. The contractions are moderate on palpation. She is having a difficult time coping with the contractions and is requesting something for pain. You assess the fetal heart tones and note that the fetal heart rate (FHR) is 130-140 with accelerations and occasional mild variables. You perform a vaginal exam and note that Cindy is 3-4 cm’s dilated and 100% effaced, with the fetus at a 0 station. 

a. What nursing actions would you perform at this time? 
b. What lab result needs to be verified? 

 

6. The physician has stated that Cindy cannot have her epidural until she is 5 cms and he would prefer not to administer any narcotics for the pain. What can you as the nurse do to help Cindy cope with her contractions? 

 

7. You have just performed a vaginal exam and determined that Cindy is now 6 cms dilated. Anesthesia has come and placed the epidural and Cindy is beginning to feel relief from the pain of her contractions. 

a. What side effects should you as the nurse monitor for in relation to the epidural? 
b. What interventions would be performed for the potential side effects? 

 

8. Cindy is complaining of “feeling a lot of pressure down there”. FHR is 120-130 with early decelerations down to 70. What nursing action(s) would you perform? 

 

9. A vaginal exam reveals that Cindy is 10cms, 100% effaced and the fetus is at a +3 station. What actions do you as the nurse need to take? What preparations need to be made for the anticipated delivery? 

 

10. Cindy delivered a 7lb 4oz baby girl. Initial assessment of the infant reveals the following: 

Heart rate = 125
Respiratory rate= slow, weak cry 
Muscle tone = some flexion 
Reflex irritability = cry
Color = body pink, extremities blue 

Determine the 1 minute Apgar score based on the above information. What actions should you as the nurse take? What factors may have influenced the infant having a slow weak cry and only some flexion of the extremities?

SCIENCE
HEALTH SCIENCE
NURSING
NURSING 254