NUR 4150 Mother Baby Simulation PRE SIM

NUR 4150 Mother Baby Simulation PRE SIM

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**Monday simulation must be submitted by Friday at 2359, Wednesday simulation must be submitted by Sunday at 2359**


Review client’s medical record (Susan Wilson) 

  • Provider Charts:
    • Provider Orders-Need to review and be aware of orders prior to SIM
    • H & P-Need to review and be aware of client history
    • Progress Notes-Need to review notes
    • Vital Signs-Review
    • Client Charting– Review
  • Provider Prescriptions (orders)
  • Labs: Review and understand abnormal and blood typing


NUR 4150 Mother Baby Simulation PRE SIM: Pathophysiology (7 points total)


  1. Compare estimated blood loss (EBL) to quantified blood loss (QBL) as utilized in the obstetrical setting. Explain “how” loss is calculated. Which part of the nursing process does this satisfy? (Cite your sources; 2 points)


  1. Complete the following postpartum hemorrhage care management (Cite your sources; 3 points/1 point each section):
    1. List 3 factors that place Susan at risk for a postpartum hemorrhage:
      1. __________________________________________________
      2. __________________________________________________
  • __________________________________________________
  1. List 3 nursing assessments to manage a postpartum hemorrhage:
    1. __________________________________________________
    2. __________________________________________________
  • __________________________________________________
  1. List 3 nursing interventions to manage a postpartum hemorrhage:
    1. _________________________________________________
    2. _________________________________________________
  • _________________________________________________


  1. Complete the following newborn care management (Cite your sources; 2 points/1 point each section):
    1. List 3 nursing assessments for the newborn transition period:
      1. _________________________________________________
      2. _________________________________________________
  • _________________________________________________
  1. List 3 nursing interventions anticipated in the newborn transition period:
    1. _________________________________________________
    2. _________________________________________________
  • _________________________________________________


Potential Nursing Diagnoses (1 point/ 0.25 point each)


Document two potential nursing diagnoses for Susan based on her pathophysiology and two potential nursing diagnoses for her neonate based on physiology.   As these are potential nursing diagnoses, your diagnoses will be at “Risk For” nursing diagnosis.  Remember to include the nursing diagnosis and the related to factor in your potential nursing diagnoses for your client.  Please come to simulation prepared with appropriate interventions for your client based on your potential nursing diagnoses. 



Potential Nursing Diagnosis #1-Susan
Potential Nursing Diagnosis #2-Susan
Potential Nursing Diagnosis #3-Neonate
Potential Nursing Diagnosis #4-Neonate




Communication (2 points / 0.5 point each)


You are the primary nurse calling Dr. Loose to communicate the current cervical exam at 0600. Using the space provided, briefly write out the “SBAR” you would use to effectively report your findings.

Situation: (Who are you? Who are you reporting about?)


Background: (Pertinent prenatal/medical history)


Assessment Findings: (VS, fetal heart tones contraction pattern, etc.)


Recommendation/Request: (What do you want? What do you suggest?)


Medical Record for Susan Wilson

Client Information:

Name: Susan Wilson

DOB: 4/13/___

Age: 42

Provider:  Kelly Loose MD

Record number: 5600326

Home address: 1112 Main St

City: Grand Rapids

St: MI

Zip code:


Phone: 555-432-9678

Marital status: married:  Jarod Wilson

Education:  College

Occupation: Preschool teacher


Father of Baby: Jarod Wilson currently deployed


Prenatal Visits

Add prenatal visits

Visit Number 1 2 3 4 5 6 7 8
Date/Weeks Gestation 10 weeks 14 weeks 18 weeks 22 weeks 26 weeks 30 weeks 32 weeks 34
Medications         Rhogam      
Weight 147 150 153 157 162 166 170 174
Blood Pressure 120/68 122/70 118/68 120/70 124/70 116/66 122/70 118/70
Urine Protein Negative Negative Negative Negative Negative Negative Negative Negative
Urine Glucose Negative Negative Negative Negative Negative Negative Negative Negative
Edema None None None None None None None None
Fetal Heart Rate 155 155 150 145 145 140 135 140
Fundal Height Not palpated 14 18 22 26 29 33 34
Fetal Activity NA NA NA Present Present Present Present Present
Presentation NA NA NA NA Cephalic Cephalic Cephalic Cephalic
Preterm Labor Symptoms None None None None None None None None
Next Appointment 4 weeks 4 weeks 4 weeks 4 weeks 4 weeks 2 weeks 2 weeks 2 weeks


Medical History


History of Substance Use


Positive History of Tobacco Use

Yes No

Number of Years Smoking

-SELECT- Less than 1 1 2 3 4 5 6 7 8 9 10 or More

Smoking During this Pregnancy

Yes No

Type of Tobacco Used:


Positive History of Alcohol Use

Yes No

Number of Years of Alcohol Use

-SELECT- Less than 1 1 2 3 4 5 6 7 8 9 10 or More

Alcohol Use During this Pregnancy

Yes No

Drinks per Day (average):

-SELECT- 1 2 3 4 5 or more

Illicit Drug Use (Prescription or Street)

Positive History of Illicit Drug Use

Yes No

Number of Years of Drug Use

-SELECT- Less than 1 1 2 3 4 5 6 7 8 9 10 or More

Drug use During this Pregnancy

Yes No

Drugs Used:

Family History

Pertinent Family History:

Review of Systems (serious illness, injury, chronic diseases)

Pertinent Review of Systems:



Immunization Status

Tetanus, Diphtheria, Pertussis (Td/Tdap):

Current Partial Doses Received

Never Received Cannot Remember

Human Papillomavirus (HPV):

Current Partial Doses Received

Never Received Cannot Remember


Current Partial Doses Received

Never Received Cannot Remember





Never Received Cannot Remember

Measles, Mumps, Rubella (MMR):

Current Partial Doses Received

Never Received Cannot Remember



Never Received Cannot Remember


Current Partial Doses Received

Never Received Cannot Remember

Hepatitis A:

Current Partial Doses Received

Never Received Cannot Remember

Hepatitis B:

Current Partial Doses Received

Never Received Cannot Remember



Never Received Cannot Remember





Admission History


Created By: B Moore, RN  Mon | 23:55

Completed By:  B Moore, RN  Mon | 23:55

Admission Data


Information received from: Self

Pregnancy Related: yes

Arrived By: Ambulatory

This Admission: OB triage


Health History

Recent Fever Requiring Antibiotics

No recent fever



Birth control used: Yes, Prior to this pregnancy.  “Worked fine, not problems really”

Sex of partners: Male

Number of sex partners: 1

Sexually active: Yes

Respiratory Problems:  Asthma, “Has not bothered me for a while. Couple years ago had bad allergies and it bothered me.”



Previous Pregnancy

How long ago? 15 years 12 years 8 years
Gestational Weeks 39.6 40.1 38.6
Type of Delivery Spontaneous vaginal birth Spontaneous vaginal birth Spontaneous vaginal birth
Duration of Labor “maybe 12 hrs” “about 6 hours” “about 8 hours.”
Complications None None None
Outcome Living male Living male Living male


Last Oral Intake

Description of intake:  Ice cream

Time: 20:00

Day: Yesterday evening


History of Current Pregnancy

Is fetus active?  Yes “Moves all the time.”


Multiple gestation?  No


Group B Streptococcus status:  Negative


Risk factors identified:  Exercise, seatbelts, Pap smears, mammograms


Provider name:  Kelly Loose, MD


Received prenatal care?  Yes






Obstetric History

Living:  3

Abortion: 0

Preterm: 0

Term: 3

Para: 3

Gravida: 4


Are you breastfeeding?  Yes “I breast fed my other 3 for 7-9 months.  The beginning was the hardest after the first week went great.”


Last menstrual period: 39.5 weeks ago

Confirmed by ultrasound? Yes

Baby’s due: 2 days from now

Are you pregnant? Yes




Planning for Hospital Stay

Newborn Plans

Newborn nutrition:  Breastfeeding

Pediatrician name:  Dr. Brown


Plans for Birth

Name(s) of person(s) to be present:   Jarod “my husband was supposed to be here but he is deployed right now.  He can’t leave until tomorrow.”

Education Level:  Graduated from college

How do you prefer instructions? Spoken and written

Do you have a living will?  “Yes the military requires it.”


Primary Language:   English

Do you have barriers to learning?  No

Can you write?  Yes

Can you read?  Yes


Why were you admitted to the hospital?

“My water broke.”

How long has the problem existed? ”Today about an hour ago.”


With whom should we communicate while you are hospitalized?  Self “I guess my parents and Jarod if he calls.”

Will family/others be staying with you during hospitalization?  “I am not sure I still have not been able to reach Jarod.  My parents are with the boys.”


Allergy Information

Do you have any known allergies to drugs, food, or environmental items?   Not really some outside stuff”


Home Medication Information

Do you take any medications, herbal products, vitamins, or supplements at home?  Yes


Information Received From:



Prescription Medications

Name Dose/Form Route Frequency Last Dose Indication Entered By Entered Day/Time
Prenatal Vitamins with Minerals and Iron – (StuartNatal, StuartNatal Plus 3, Duet, NataChew, Prenatabs) 1 tab/Tablet Oral Daily Prenatal health B Moore, RN Mon 23:55
Albuterol HFA Inhaler – (Ventolin HFA, Proventil HFA, ProAir HFA) 90 mcg/actuation 2 inhalations/Inhalation Aerosol Inhaled Every 4 Hours PRN

Years ago

Have problems breathing. B Moore, RN Mon 23:55

Drug Screen


Street/Recreational/Excessive Prescription Drug Use: “I have never used street/recreational/excessive prescription drugs.” Urine sent for tox screen.



Smoking Screen


Smoker Status:  “I have never used tobacco.” Do you live with a smoker? No



Alcohol Screen : Do you drink alcohol?  No



Mobility and Physical Therapy Screen

Does patient have orders for physical therapy? No



Morse Fall Scale

Total Fall Risk Score

Risk Score:



Fall Risk Score and Preventative Measures Implemented

Fall Risk Level:

Low Risk


Fall Risk Measures:

Implement <b>Low</b>  Risk Fall Prevention Interventions:<br>All admitted patients, orient to surroundings, patient and family education about risk, toileting program, bed in low position, evaluate medication response, personal items in reach, night light as appropriate, nonskid footware, decrease room clutter.


Mental Status


Oriented to Own Ability=0






IV or IV Access




Ambulatory Aid


None/Bedrest/Nurse Assist=0


Secondary Diagnosis




History of Falling




Fall Risk Assessment

Risk Level


Low risk


Morse Fall Scale

Fall Risk Assessment score:



Activity/Occupational Therapy Screen

New Occupational Therapy Screen


No new occupational therapy problems noted at this time


Psychosocial Screen

Cognitive Ability


Recall 5 object names 3 minutes after mention?  Yes


Can recall place of birth? Yes


Can recall year Born?  Yes


Can recall mother’s maiden name?  Yes


Abstract Reasoning (Able to Report Logical Response)

A bird in the hand is worth two in the bush: Yes correctly explained this statement.


A rolling stone gathers no moss: Yes


Attention Span

Can correctly say the days of the week: Yes


Can correctly spell “world” backwards: Yes



How well is client meeting social and family obligations? Meets


What are your plans for the future? Appropriate



Can follow simple directions: Yes


Can follow complex directions: Yes



Can communicate verbally: Yes



Grooming: Clean, with good grooming




Emotional Status

Body language: Erect posture with good eye contact


Over the past 2 weeks, have you felt down, depressed, or hopeless? No


Over the past 2 weeks, have you had little interest in doing things? No



Oriented to time: Yes


Oriented to person: Yes


Oriented to place: Yes


Nutrition Screen

Food Preferences/Diet Considerations

Diet before hospitalization, including snacks: 3 meals per day, usually an evening snack before bed.


Total Score




Illness/Injury Nutrition Screen

Fever/infection/sepsis:  0 = No


Polytrauma/multiple fracture:  0 = No


Tube feeding/total parenteral nutrition (TPN):  0 = No


Pressure ulcer/open wounds/draining fistula:  0 = No


Head/neck/mouth surgery:  0 = No


Cachexia or physical signs of weight loss:  0 = No


Total Score  0


General Nutrition Screen

Diet information requested by patient:  0 = No


Tube feeding/total parenteral nutrition (TPN):  0 = No


Pressure ulcer/open wounds/draining fistula:  0 = No



Social Interactions


Describes self as outgoing and friendly


Social Resources


Will have strong support/help with newborn


Feelings of Readiness for Newborn Care


Feels ready, eager



Readiness for Newborn

Supplies and equipment at home:

Car seat








Hygiene supplies


Role Performance


Good self-identity and role identity


Caregiver Role


Primary caregiver in family for 1 or more family members


Family Processes


Participates as decision-maker in family


Marital or Partner Status





Case Management and Social Work Screen

Case Management

Do you currently have a home health nurse visiting you?  No


Was client admitted from another hospital or facility?  No


Do you currently use oxygen or medical equipment at home?  No


Do you anticipate the need for home infusion or enteral needs?  No


Have you been hospitalized more than twice in the past 2 months?  No


Abuse Screen

Are there physical injuries consistent with the patient’s history?  No


Is there any person who threatens you or hurts you?  No


Have you been forced into sexual activities against your wishes?  No


Case Management

Do you anticipate the need for health services or medical equipment?  No


Do you have difficulty obtaining your medications?  No


Do you anticipate the need for self-injections at home?  No


Abuse Screen

Have you been hit, slapped, kicked or physically hurt by someone in the past year?  No


Are you afraid of your partner or someone else?  No


Have you been emotionally or physically abused by your partner or someone else?  No


Social Work

Is client homeless or unidentified?  No


Will you need assistance after discharge?  No


Is client a candidate for nursing home care?  No


Will you have assistance after discharge?  Yes



Religious Preference


Christian, reformed


Do you want clergy to visit you while you are in the hospital?  No


Are there religious, cultural, or ethnic concerns we should consider while you are in the hospital? No


Pressure Sore Risk Assessment: Braden Scale

The Braden Scale for Predicting Pressure Sore Risk

Total Braden Scale score:



Total Braden Scale Pressure Sore Risk Factor


Not at Risk: Score of 19 or higher.



Braden Scale

Total Braden Scale Pressure Score Risk Factor

Total Braden Scale Score

Not at Risk





Friction and Shear

Degree to which skin is at risk for friction or shearing wounds:

NO APPARENT PROBLEM = 3 Moves in bed and chair independently and has sufficient muscle strength to lift up completely during move.Maintains good position in bed or chair.



Usual food intake pattern:

ADEQUATE = 3 Eats over half of most meals. Eats a total of 4 servings of protein (meat, dairy products) per day. Occasionally will refuse a meal, but will usually take a supplement when offered OR is on a tube feeding or TPN regimen which probably meets most of nutritional needs.



Ability to change and control body position:

NO LIMITATION = 4 Makes major and frequent changes in position without assistance.



Degree of physical activity:

WALKS OCCASIONALLY = 3 Walks occasionally during day, but for short distances, with or without assistance. Spends majority of each shift in bed or chair.



Degree to which skin is exposed to moisture:

RARELY MOIST = 4 Skin is usually dry. Linen only requires changing at routine intervals.


Sensory Perception

Ability to respond meaningfully to pressure-related discomfort:

NO IMPAIRMENT = 4 Responds to verbal commands. Has no sensory deficit which would limit ability to feel or voice pain or discomfort.


Pain Assessment

Intensity of Pain

2  “Just when I have a contraction, not bad at all.”


Location of Pain




Do You Have Pain Now?



Pain Management Risk Assessment

Pain Assessment score:  2 using 1-10 scale 1 being minimal pain, 10 being maximum pain


Are you currently experiencing pain? Yes



Admission Forms Verification

Admission Forms Verification


Verified consent to treat in admission packet


Unit Orientation

Bracelet Check

Bracelets placed on client:  Hospital ID bracelet


Information given to: Client


Instructed on:

Call light


Emergency light in bathroom


Lights in room


Bedside controls


Side rail policy




TV control


Meal times and snacks


Visiting hours


No-smoking policy


Guest information


Safety tips


Fetal monitor


Newborn nursery


Rooming in


Newborn identification process



Instructed on all unit policies and procedures and oriented to all room features






Risk Alerts:

Fall Risk: no


Pressure Sore RiskNot at Risk

Obstructive Sleep Apnea Risk: none at this time


 Problem List

Medical Diagnosis:

Primary Diagnosis:  Pregnancy, term

Secondary Diagnosis:  Labor


Nursing Diagnosis: Fluid Volume, Pain, Anxiety


 Active Invasive Items

IV Lines:   01:25    Left Dorsal Basilic (Hand)  Peripheral


Drains/Tubes: None

Basic Information

Code Status: Full code

Allergies: NKA

Isolation Status:  No  

Alerts: No




Chart Time Temp Resp Pulse BP Sat% Pain  Intake   Output   Entry By
02:15 98.8 18 90 110/64 99% 2 Oral


 Void BR

1000 mL

  L Smith, RN
 03:00 98.8 18 90 112/64 2 150mL     L Smith, RN
04:00 98.6 18 90 115/68 Eyes closed       L Smith, RN
05:00 98.4 18 90 120/70 2 sips BR

400 mL

  L Smith, RN
06:00 98.6 18 86 120/66 4 IV  350 mL     L Smith, RN





Chart Time Fetal Heart Rate Decels Contraction Frequency  Intensity Cervical Dilation (cm)
02:15 120-130 External  0 Irregular about every 2-6  mild 2 cm 75%
03:00 125-130 External 0 More regular every 5  mild
04:00 Not taken   Client eye closed observed 10 mins    
05:00 130 External 0 Every 3  Mild -mod
06:00 140-150 Mild early Every 3  mod 4 cm 90%

Lab Values



  • Hemoglobin 13.0 g/dL
  • Hematocrit 40%
  • Blood Type: A-  (Completed at first OB appt)
  • GBS (group beta strep): Negative
  • Rubella: Immune
  • Gonorrhea/Chlamydia: Negative
  • Hep B: Immune





Orders per Dr Loose and Sarah Brown

Pre Delivery:

  • Routine pre delivery labs
  • Diet as tolerated, ice chips when active labor
  • IV LR @ 125 mL/hr
  • Epidural if requested after 5 cm dilated not after 8cm (primip) 7cm (multip)
  • Oxytocin augmentation 1mu/hr titrate every 15 mins until labor established: contractions q 3 mins, mod intensity, no fetal decelerations.
  • Nalbuphine 10mg IM or slow push IV q 3 hours prn do nto exceed 160mg/24hr.


Post Delivery:

  • Routine postpartum VS, fundal and lochia assessment
  • 30 units oxytocin in 500 LR run as needed to control bleeding begin at 125ml/hr double every 15 minutes until 500mL/hr running then notify on call provider.
  • Straight urinary cath if needed.
  • Ducosate Sodium 100mg/day
  • Witch Hazel pads
  • Acetaminophen 650mg po q6 hours prn pain
  • Saline lock after 4 hours post-delivery and lochia stable
  • D/C saline lock after RhoGAM 300 µg if required.


Newborn Orders

  • NRP guidelines
  • Routine newborn labs
  • VS q 15 x4, q30 x 4, q 4 hr
  • Type for Rh
  • Breastfeed on demand
  • Consult lactation consultant
  • Vitamin K 1mg IM
  • Hep B 0.5mL IM
  • Erythromycin one thin ribbon each eye






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