Case Study 1

A patient presents to triage with vaginal bleeding that started this morning (prefers they/them
pronouns). They state they saturated a large perineal pad on their way to the hospital. They are a
G2P0101 with a history of a cesarean delivery (C/S) at 34 weeks for IUGR, and is currently 31
weeks. They do not report any pain.
VS: temp 98.9, HR 110, RR 18, BP 89/45
Assessment findings: FHR baseline 155 with moderate variability and no decels, moderate
amount of bright red bleeding on perineal pad, no clots noted. Abdomen is soft, nontender to
palpation. Pt reports feeling dizzy.

Complete the diagram by writing from the choices below to specify what condition
the client is MOST likely experiencing, 2 actions the nurse should take to address that
condition, and 2 parameters the nurse should monitor to assess the client’s progress.

Bleeding amount/frequency/
Administer
Betamethasone characteristics
Placenta
Previa
Continuous Fetal
Coag Panel
Monitoring

Actions to Take Potential conditions Parameters to Monitor

Encourage ambulation labor Bleeding
amount/frequency/characteristics
Perform cervical exam Pre-eclampsia Liver enzyme studies
Administer indomethacin Gestational diabetes Coagulation panel-fibrinogen,
PTT/INR, platelets, Hgb/Hct
Administer betamethasone Placenta previa Protein/creatinine ratio
Continuous fetal monitoring Placental abruption HgA1C

The most likely condition that this patient is experiencing is a placenta previa
considering they are reporting painless bright red vaginal bleeding. Because of the placenta
previa the medical team must be careful to avoid a cervical exam or putting anything in their
vagina other than a potential speculum exam, as these things could exacerbate the bleeding. The
patient should remain on strict bed rest for the same reason. Indomethacin is a tocolytic which
would not necessarily be helpful in this situation as the patient is not contracting. Therefore the
two actions to take would be administering betamethasone (used for lung maturity) and
continuous fetal monitoring (to assess for signs of fetal distress). The best two parameters to
monitor are the bleeding amounts and characteristics and a coagulation panel to assess the
patient’s risk for excess bleeding. Monitoring Liver enzyme studies, protein/creatinine ratio and
HgA1C are all important tests but not directly helpful for placenta previa.

Q: what are 3 risk factors for this condition? Select All That Apply (SATA)
1. previous pregnancy with the condition
2. previous c/s
3. maternal obesity
4. illicit drug use
5. poor prenatal care
Any pt with placenta previa is at risk of having it with subsequent pregnancies. In addition, any
patient with a prior uterine scar (including c/s) is at risk of placenta previa because the placenta
tends to implant in an abnormal location in the uterus in early embryonic development. Illicit
drug use (particularly cocaine) also will cause this placental abnormality. Maternal obesity and
poor prenatal care have no correlation to placenta previa.
Q: What of their assessment findings is the most concerning?
1. bleeding
2. BP
3. HR
4. FHR baseline
Though the first 3 answers are all important to address, the most important is the blood
pressure, as it is dangerously low. The bleeding, though moderate, is not severe and does not
have clots. The HR is mildly elevated but is not surprising considering the patient’s blood
pressure and fear in the situation. The FHR baseline is normal and reassuring.

Page 2
The patient gets an IV started; with some bedrest and fluids their blood pressure is now 112/62,
HR 102. Bleeding has turned into light brown spotting. Pt is about to be given betamethasone
IM.

Q: What statement by the patient demonstrates adequate education?

1. “this medication is to help stop the bleeding so that I can have a vaginal delivery”
 2. “this medication is for my baby’s lungs to mature in case I need to deliver early”
3. “This medication is a steroid that relaxes my uterus to prevent contractions because I
will need a c-section”
4. This medication is given because I had bleeding in my pregnancy, and because my
blood type is O negative I will need this shot during every pregnancy, when I have bleeding, and
after I deliver to prevent harming future pregnancies.”

The second answer is the direct reason why betamethasone would be administered. The first
answer is not correct; betamethasone has no impact on bleeding, and patients with placenta
previa will automatically need a c-section. The third answer is partially correct, but
betamethasone does NOT relax the uterus to prevent contractions. The fourth answer is the
definition of Rhogam.
The patient’s bleeding begins to increase again, saturating a perineal pad in an hour with
clots. What are your priority nursing actions? Place in order:
__1__. place U/S on the pt for monitoring FHR
__3__. notify the provider
__4__. confirm IV access and begin IV fluids
__5__. prep pt for STAT C/S
__2_. Vital signs
The typical priority nursing action when a patient is pregnant with a viable fetus is to establish
fetal well-being via electronic fetal monitoring (aka the ultrasound). The next step for this
patient should be to establish if the patient is stable with their vital signs, so that you have all of
this information to provide the doctor. The third step is to notify the provider with your
assessment results. Fourth and fifth will be to confirm IV access, begin IV fluids and prep the
patient for an urgent c/s.
The patient is crying, saying, “please save me and my baby, I don’t want to die!”
Recognizing that obstetric emergencies can cause trauma, how can you as the nurse best
meet the emotional needs of this patient? SATA
1. ask the patient about their cultural preferences for birth
2. request chaplain consult for a postpartum visit
3. reassure the patient that everything will be okay
4. actively listen to the patient’s concerns
5. bring in a different nurse to talk to the patient about their personal birth trauma
This question is referring to therapeutic communication. It is NOT therapeutic to reassure the
patient that “everything will be okay” because you cannot guarantee it, nor is it appropriate to
bring a nurse in to discuss their personal birth experiences. What IS appropriate is to find out if
the patient has special cultural practices for birth, requesting a chaplain to reflect on this scary
experience, and to actively listen to the patient’s concerns.
Page 3
Case Study 2:
You are a nurse in Labor and Delivery caring for a patient sent over from a prenatal appointment
for elevated BPs. Ana is a 35yo G1P0 at 38 weeks (she/her pronouns). Her chart reveals the
following information:
PMH: gestational diabetes (on metformin), BMI 40, anxiety, depression, asthma
Current meds: prenatal daily HS, ASA 81mg daily, albuterol inhaler PRN (last use 1 week
ago), metformin 500mg BID
Pregnancy concerns: AMA, LGA (EFW 98%), no expected fetal abnormalities, known cephalic
presentation, Group Beta Strep positive
No known allergies
Labs (most recent 1 month ago, normal values in parentheses): glucose 143 (70-120), sodium
140 (135-145), potassium 3.8 (3.7-5.2), Hgb 11.1 (11.6-15), Hct 33 (35.5-44.9), WBC 10.4 (3.4-
9.6), platelets 315 (157-371), AST 25 (8-33), ALT 35 (4-36), creatinine 0.8 (0.6-1.3), prot/creat
ratio 0.1 (<0.3)

What are the first actions you will take as the nurse triaging this patient? Highlight the
priority nursing actions
1. place pt on the monitor to measure FHR
2. take vital signs
3. ask about current symptoms
4. check her cervical dilation
5. look at her glucose log for compliance
The biggest concern that we have for this patient right now is whether or not she is developing
pre-eclampsia, which can initially be differentiated from gestational hypertension by the
patient’s symptoms. Therefore the triage nurse should be asking the patient if she has any
symptoms that would be suspicious of pre-eclampsia. And of course the nurse should be
assessing fetal wellbeing as preeclampsia can be life-threatening to the fetus. And if a patient is
being assessed for elevated BPs, then a full set of vital signs should be taken. Even though
cervical dilation will be important at some point, it is not a PRIORITY nursing action. The
patient’s glucose log is not important to their hypertension.

What are the defining characteristics between gestational hypertension, pre-eclampsia and
HELLP syndrome, and how might you differentiate between them as a healthcare
provider?

-gestational hypertension: Gestational Hypertension is two elevated blood pressures greater

than 140/90 at least 1 hour apart after 20 weeks of pregnancy. Pt is often asymptomatic and no
proteinuria is present.

-pre-eclampsia-Preeclampsia is defined by the presence of elevated blood pressures and the

presence of proteinuria. Pre-eclampsia can either be with severe features or without (formerly
called mild or severe); these symptoms include headache, vision changes, shortness of breath,
edema, nausea/vomiting, and right upper quadrant pain.
-HELLP syndrome-HELLP syndrome is most often considered an advanced form of pre-
eclampsia, typically diagnosed with the hallmark conditions of hemolysis (low hemoglobin, for
example), elevated liver enzymes, and low platelets. These patients likely also have symptoms of
preeclampsia including elevated blood pressures and proteinuria.
Page 4 (continued case study 2)
You are a nurse in Labor and Delivery caring for a patient sent over from a prenatal appointment
for elevated BPs. Ana is a 35yo G1P0 at 38 weeks (she/her pronouns). Her chart reveals the
following information:
PMH: gestational diabetes (on metformin), BMI 40, anxiety, depression, asthma
Current meds: prenatal daily HS, ASA 81mg daily, albuterol inhaler PRN (last use 1 week
ago), metformin 500mg BID
Pregnancy concerns: AMA, LGA (EFW 98%), no expected fetal abnormalities, known cephalic
presentation, Group Beta Strep positive
No known allergies
Labs (most recent 1 month ago): glucose 143, sodium 140, potassium 3.8, Hgb 11.1, Hct 33,
WBC 10.4, platelets 315, AST 25, ALT 35, creatinine 0.8, prot/creat ratio 0.1

Nurses’ notes
0930: BPs 171/110, 180/105. Provider notified. STAT IV placed and labetalol 20mg
administered. labs drawn and sent. Follow-up BP 147/95. Pt reports H/A, floaters in vision for 2
days, new onset of chest pain this AM. Reports mild RUQ pain, pt thought it was braxton-hicks
contractions. Denies N/V. Reports positive fetal movement, denies vaginal bleeding or loss of
fluid. Urine collected and sent.

0945: given tylenol 975mg PO for headache

1030 lab results (normal in parentheses):

Sodium (135-145): 139
potassium (3.7-5.2): 4.1
Calcium (8.5-10.2): 8.9
Creatinine(0.6-1.3): 0.9
AST (8-33): 28
ALT (4-36): 30
Prot/creat (<0.3): 0.5
WBC (3.4-9.6): 9.6
Hgb (11.6-15): 10.7
Hct (35.5-44.9): 34
Platelets (157-371): 195

1045: BPs remain elevated 140s-150s/90s. None severe range after labetalol dose. Headache
unrelieved with tylenol, MD notified.

1100: pt diagnosed with pre-eclampsia with severe features

The patient asks if she can go home because she has to get ready for her evening shift
position. What response is best for this patient?
1. You can’t go home because you’re going to be having a c/s soon
2. It is unsafe to go home with your diagnosis of pre-eclampsia, and the doctors are
planning the next steps in your plan of care for delivery
3. You are very sick and going home would harm your baby.
4. We will be giving you pitocin soon to induce you, so no you cannot go home
The first answer is incorrect because the patient is not automatically getting a c/s due to her pre-
eclampsia. The third answer is not an example of therapeutic communication. The fourth answer
is assuming the induction method (when a bishop score has not been determined yet). The
second answer is correct as it gives the patient correct information while being therapeutic and
not making assumptions about the plan of care.

The doctors plan to induce her for her pre-eclampsia but need to do a few things before
starting. What are some of the orders/actions that you would expect? SATA
1. Start Magnesium Sulfate for seizure prophylaxis
2. Administer Rhogam
3. Perform cervical exam to determine plan of care for induction
 4. Intermittent fetal monitoring
5. Test for Group Beta Strep
This question is looking for you to think of what orders might be given for a patient with pre-
eclampsia with severe features. Magnesium Sulfate would be appropriate for seizure
prophylaxis, and performing a cervical exam is appropriate to determine the next steps in her
induction. Rhogam is not indicated at this time as she is term and had no vaginal bleeding.
Intermittent fetal monitoring is only appropriate for low risk patients, not for a patient with pre-
eclampsia. Finally, testing for Group Beta Strep is not indicated as patient has already tested
positive (check pregnancy concerns in the initial medical history).

The patient’s Bishop score is 7. What orders would you question? SATA
1. Cervidil or dinoprostone gel x12 hours
2. Cook catheter/foley bulb placement
3. Start pitocin at 2mu/min, slowly increase until at 20mu/min
4. Start pitocin at 20mu/min and increase as tolerated
5. Bedrest with bathroom privileges
6. Continuous fetal monitoring

A Bishop score of less than 6 would require a cervical ripening agent; a score of 8 or more is
fairly predictive for a successful vaginal birth. This Bishop score is 7 and therefore does not
necessarily need cervical ripening. Therefore ripening agents are not appropriate, including
cervidil, dinoprostone gel, and cook catheter placement. The third answer is an appropriate
order for pitocin. The fourth answer recommends pitocin START at 20mu/min, when this is
typically the maximum given. Bedrest with bathroom privileges is appropriate for a patient on
seizure precautions. Continuous fetal monitoring is required for a patient with preeclampsia.
Page 5
Nurses’ notes
1230: pitocin started, FHR baseline 140, moderate variability and accelerations present, no
decelerations noted. maternal BPs 120s/70s on Magnesium Sulfate drip, seizure precautions in
place.

1430: Spontaneous Rupture of Membranes at 1430 for clear fluid.

1500: pitocin now at 20 mu/min, provider notified. Pt requesting epidural, orders placed by MD.

1530: pt comfortable with epidural. Sterile Vaginal Exam 6cm. FHR with minimal variability, no
accelerations present, late decelerations noted.

Q: Which actions are appropriate for the nurse to take at this time? SATA
1. Turn off epidural
2. reposition to L lateral
3. oxygen
4. give pt something to eat
5. fluid bolus
6. notify provider
7. D/C pitocin
 8. assess VS
This question is directly related to nursing interventions for decelerations on the final page of
the intrapartum monitoring powerpoint. The first action would be to position the patient
laterally (particularly left lateral). Then consider administering oxygen and a fluid bolus for
fetal rescucitation. Discontinuing pitocin and notifying the provider are also appropriate
considerations. Finally, though not on the powerpoint slide, it is appropriate to check vital signs
as the patient recently got an epidural which can cause hypotension and therefore decreased
placental perfusion.
Q: If the patient were to continue to have late decelerations despite interventions, the nurse
knows that this means _______________ and that they should prepare for _____________.
Please choose one from each category to fill in the respective blanks.
The fetus is well oxygenated Blood administration
The placental perfusion is Vaginal delivery
compromised
The fetus head is not going to Pitocin for augmentation
fit in the pelvis
The patient has a uterine Cesarean delivery
rupture
The reason why late decelerations occur is because of “placental insufficiency” aka decreased
placental perfusion to the fetus. If they are not resolved with possible interventions the next step
is typically to head towards cesarean delivery. Though a uterine rupture might cause late
decelerations and would indicate a cesarean delivery, late decelerations do not ALWAYS mean a
uterine rupture (as this is a rare medical emergency).

Q: The doctor consents for the patient for a cesarean delivery due to recurrent FHR
decelerations and remote from delivery, as pt was only 6cm dilated. Pt is tearful and
asking, “Did I do something wrong?” What is the best response for this patient?
1. “no of course, not! Stop thinking like that!”
2. “well your poorly controlled gestational diabetes didn’t help anything”
3. “there are a lot of reasons why this could have happened”
4. “sometimes placental perfusion is impacted by pre-eclampsia, which is not your fault.
How can I help support you?”
This question is assessing for therapeutic communication again, and the first two answers are
definitely not therapeutic. The first answer does not allow the patient an opportunity to express
what they are feeling, and the second places unnecessary blame on the patient. The third answer
is true but it is not the BEST response; the fourth answer allows the patient to discuss their
feelings and concerns while also being reassured that they have not caused the fetal distress.

Q: What are some possible complications related to each mode of delivery? At least one
symptom will be in each column and could be applicable to both.

Vaginal delivery Cesarean delivery

Postpartum hemorrhage X X
Infection of surgical repair X X
Malignant hyperthermia X
Damage to internal organs X X
 Paralytic ileus X
Risk for placental X
abnormalities in future
pregnancies
Perineal lacerations X
Aspiration X
Abdominal adhesions X

-postpartum hemorrhage-possible in both modes of delivery

-infection of surgical repair-incisional infections are common for c/s, but technically a perineal
laceration or episiotomy repair could get infected too
-malignant hyperthermia-an allergic response to general anesthesia which would only be
administered in a c/s
-damage to internal organs-c/s is more likely to injure tissues due to the surgery, but a vaginal
delivery could also negatively impact bladder function or have a rectovaginal fistula from a
severe laceration
-paralytic ileus- this a condition where a portion of the intestines postoperatively fails to digest,
thus it is only a possible result from c/s
-risk for placental abnormalities in future pregnancies: This is referring to placenta previa and
placenta accreta (a condition where the placenta adheres into the myometrium or surrounding
organs); these conditions are more likely with a uterine incision aka a c/s
-perineal lacerations-these are specifically found in the perineum and would not occur in a c/s
-aspiration-a complication from general anesthesia (only in a c/s)
-abdominal adhesions-this is scar tissue that is formed in the abdomen after surgery
Page 6
Case Study 3: (standalone)

A client presents to the hospital for a term labor check. Elliot (he/they) is a G7P6006, reports
contractions are coming every 3 minutes, lasting for 1 minute and are very strong and painful.
They started less than 1 hour ago at 0230 when his water broke for clear fluid. Pt states, “we got
in the car as soon as my water broke because my labors are typically very quick”. Pt reports
feeling rectal pressure and an urge to push. Upon arrival to the hospital pt is too uncomfortable to
sit still, reports having to stand at the bedside. FHR doppler obtained, HR 145. VS: HR 125, BP
141/79, temp 99.2, RR 24. Sterile vaginal exam reveals cervical dilation 10/100/0, pt bearing
down involuntarily. Pt rushed up to labor and delivery where infant was delivered 11 minutes
later at 0344.

Highlight the aspects in the vignette above that would lead you to believe this patient is
experiencing a precipitous delivery.

The potential risk factors from having a precipitous delivery include ___________ and
___________.
1. hemorrhage and preeclampsia
2. Hemorrhage and fetal respiratory distress
3. Postpartum depression and hypotension
4. Poor pain control and placental abruption
A precipitous delivery makes a patient more likely to have a postpartum hemorrhage, and the
newborn is more likely to struggle to transition initially to breathing on their own. The patient is
not more likely to experience preeclampsia or placental abruption. Postpartum depression could
occur as a result of a traumatic delivery, but it is not directly caused by a precipitous delivery.
Hypotension could occur as well, but more so related to a postpartum hemorrhage, not from
delivering quickly. Finally, pain control in the moment may not be controlled well due to an
inability to get an epidural placed in time, but postpartum pain is typically controlled the same
as any other delivery.