You are working in a high risk L&D unit and just received a call from Dr Green s

Question

You are working in a high risk L&D unit and just received a call from Dr Green saying that he is sending in a 38 year old approximate 32wk G2P1 in for elevated blood pressures in the office and is needing an NST, continuous monitoring of BP and further labs. The patient was a drop-in to the clinic without previous prenatal care. She is unsure of her LMP and states that her two year old son “came early” at 36 weeks which was a vaginal delivery without any anesthesia, “because he came so fast”. She is not reporting any contractions or pain at this time. During her office visit she presented at 2/70/-3. She has no support person with her.

You are about to call Dr Green back with your findings.  

Using SBAR describe the following:

BP 180/100, P 88, R 22, T 100.2.

HA 4/10

Reactive 20 minute NST (what does this mean)

SVE 2/80/-3, membranes intact

Irregular mild to palpation cx noted q 4-8 mins

Explanation / Answer

SITUATION :

Mrs. M is a 38 year old approximate 32 week G2P1, with elevated blood pressure, LMP unknown, no history of prenatal care.

BACKGROUND :

Mrs. M has a history of pre - term delivery at 36 weeks which was a normal vaginal delivery with no anesthesia.

ASSESSMENT :

Mrs. M current vital signs are blood pressure - 180/100 mm of Hg, Pulse - 88 beats/ minute, Respiration - 22 breaths /minute,Temperature - 100.2 degree fehrenheit. Histamine concentration is 4/10. Non stress test are normal with reactive 20 minute. sterile vaginal examination reports 2 cm dilated, 80 cm effacement, and -3 cm station. Membranes are intact, irregular mild on palpation,cervical length noted 4-5 mins.

RECOMENDATION :

I recommend to provide comfort, well ventilated room and tapid bath to bring down the temperature and blood pressure avoiding any medications. Would you like me to administer medications to treat her hypertension and what medication would you like me to administer.

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