Anne Jones, 17 years old
Primary Concept
Pain
Interrelated Concepts (In order of emphasis)
1.
Perfusion
2.
Stress
3.
Anxiety
4.
Reproduction
5.
Clinical Judgment
6.
Communication
7.
Collaboration
NCLEX Client Need Categories
Percentage of Items from Each
Covered in
Category/Subcategory
Case Study
Safe and Effective Care Environment
• Management of Care
17-23%
✓
• Safety and Infection Control
9-15%
Health Promotion and Maintenance
6-12%
✓
Psychosocial Integrity
6-12%
✓
Physiological Integrity
• Basic Care and Comfort
6-12%
✓
• Pharmacological and Parenteral Therapies
12-18%
✓
• Reduction of Risk Potential
9-15%
✓
• Physiological Adaptation
11-17%
✓
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History of Present Problem:
Anne is a 17-year-old, gravida 1 para 0 who is 39 weeks gestation and admitted to the labor room for
observation at 1200. She began having contractions three hours ago at 8 to 10-minute intervals with each
contraction lasting 30 seconds. She states her pain is 3/10. Her membranes are intact. On admission, a vaginal
exam indicates cervical dilation is 1 cm, 80% effacement, and 0 station.
After two hours of observation, her cervix is 2-3 cm/ 80% effacement/0 station and contractions are now 4-
5 minutes apart, lasting 60-70 seconds and pain remains 3/10. Fetal lie is longitudinal with a cephalic
presentation. You have her prenatal records from her visits to the office. She is Group Beta Strep (GBS)
positive and received antibiotics at 36 weeks. Her blood type is B-.
Personal/Social History:
Anne’s mother is with her. Anne is not married and the father of the baby is not involved. She appears to be
relaxed although she states she is a bit nervous. She wants a natural non-medicated birth and her mother will
help coach her. She plans on breastfeeding for “awhile”. She attended childbirth preparation classes with her
mother.
What data from the histories are RELEVANT and must be interpreted as clinically significant by the nurse?
(Reduction of Risk Potential)
RELEVANT Data from Present Problem:
Clinical Significance:
Contractions 8-10 min intervals, lasting 30 In the first stage of labor, latent phase.
seconds, dilation 1, 80% effaced, 0 station
cervix is 2-3 cm/ 80% effacement/0 station Now in active labor. The babies head is currently located at
and contractions are now 4-5 minutes
station 0 so that indicates that the baby is descending in her
apart, lasting 60-70 seconds and pain
pelvis correctly.
remains 3/10. Fetal lie is longitudinal with
a cephalic presentation.
Anne has received antibiotics for her + GBS. After the
She is Group Beta Strep (GBS) positive
delivery of the baby, she will need a shot of RhoGAM, with
and received antibiotics at 36 weeks. Her
her informed consent, to prevent her body from producing
blood type is B-.
antibodies against the babies blood (in case the baby is a +.
RELEVANT Data from Social History:
Clinical Significance:
Single mother but has support from
mother.
Plans on breastfeeding
Desires a non-medicated birth and hasattended childbirth preparation classes.The nurse will need to provide education to not only Anne after
delivery, but the mother as well since she is her support system.
Schedule lactation consult for education on breastfeeding.
Nurse can help educate the mother how to coach Anne through
contractions, the nurse will help provide non-medicated ways to
labor naturally such as an exercise ball, breathing techniques,
massage and position changes.
Anne is placed on a fetal monitor and
the nurse collects the following strip:
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