NURSING ASSESSMENT DAY 1: 31 years old female, 39 weeks gestation was scheduled to come in today to be induced, but her body started labor on its own. She came complaining of painful contractions that were coming closer and closer. Pain level 6 in scale 1-10. Amniotic sac intact at this time. Cervix dilated at 3 cm. Patient was admitted at labor and delivery unit at DHR at 0630, SROM at 0655. NPO, fetal monitor on. Height 5"1. weight 165 Lbs. Former smoker, no history of alcohol dependence or illicit drug use. Lungs sound clear bilaterally anteriorly. Posterior lung sounds unable to be assessed due to difficulty moving because of strong pain. Bowel sounds present. Last bm 07/09/2018 around 0400 (brown, soft, formed). V/S T98.0 o, P 102, RR 22, B/P 113/76. 18 gauge IV catheter at R wrist. (site clean, no redness, swelling, drainage or pain present). Gravida 3, para 2. P0 A0 L2.
BABY'S MATHEW ASSESSMENT: Was born at 1130. Apgar score 9 at 1 minute, 9 at 5 minutes.
weight 7 Lb 7 oz. Height not found in chart. Lungs were clear, HR 56. Vitamin K injected to L vastus lateralis.
NURSING ASSESSMENT DAY 2: 31 Years old, post delivery day 1. awake, alert x 4. G 3, T, 3, P0, A0. L3. V/S 98.4, P 90, RR 18, B/P 122/76. On regular diet (ate 100%). Lung sounds clear posteriorly and anteriorly bilaterally. Bowel sounds present, fundus checked and retracting WNL, no edema at lower extremities. IV saline lock at R wrist (site clean, no redness, drainage, swelling or pain present).No pain present. Last bm 07/10/2018 around 0600 (liquid).