B.S.

is an intelligent, shy, 5 feet and 4 inches tall, 00-year-old Caucasian female patient: G1P0, LMP is December 00, 2010, EDC is October 10, 2011 and gestation of 38.4 weeks. Pre-pregnancy weight was 135 lbs and pregnancy weight is 172 lbs for a total gain of 37 pounds. B.S stated she eats a balanced diet consisting of three meals and two snacks a day, rarely drinks alcohol (no alcohol while pregnant), and she has never smoked cigarettes or taken recreational drugs. B.S. has received prenatal care from a private MD since March 2011. No significant health problems encountered during pregnancy. Blood type & Rh A-, prenatal labs are negative. B.S. was admitted to WMC for pelvic pain, vaginal exam upon admission: dialation 3, 80% effaced, -2 station with cephalic presentation. B.S. plans to bottle-feed. NKDA. Significant medical history includes chronic ear infections as a child with myringotomy. B.S.s home medications include: prenatal vitamin 1 tab PO daily, Tylenol 500 mg PO q6h prn and pericolace 2 tab PO q h.s. No significant family medical history. B.S.s supportive and caring mother was at the bedside throughout the labor and delivery and postpartum. IV and external fetal monitoring was initiated shortly after admission. Onset of labor was 1600hrs, contraction pattern strong with moderate variability, membranes were artificially ruptured at 1630hrs, amniotic fluid was clear with no odor and no evidence of meconium. B.S. was placed on epidural for pain management throughout labor. Foley catheter was inserted after epidural. Duration of labor was 5hr. 49min. Time of delivery: 2146hrs. There were no complications throughout the labor phases; delivery was spontaneous with a 2nd degree laceration to perineal. A healthy female neonate was delivered at 2146hrs on September 25, 2011: birth weight 6lb 3 oz, length 18.75 in and APGARs 61 and 95. The umbilical cord had 2 arteries and 1 vein. The placenta was

delivered intact and spontaneously with minimal assistance. Estimated maternal blood loss was 500 mL. The mother and newborn bonded very well after birth. B.S.s IV in her right forearm and Foley catheter were discontinued 3 hr postpartum. The mother signed consent forms for all newborn tests and meds. Upon entering the room, the mother was smiling, caressing and talking to her newborn. She appears to be in the taking hold stage of bonding. The mother looked tired and stated that she had not had much sleep the prior night. The grandmother was present and held the infant during my assessment. The patients vial signs are WNL: oral temp is 98.5F, pulse is 65, respirations are 16 and blood pressure is 117/60. Full ROM in head and neck, pupils PERRLA, no ringing in ears or dizziness reported by patient. Lung sounds present in all fields and clear bilaterally to auscultation. Heart sounds clear and regular, with no murmurs. Radial and pedal pulses bilaterally equal and strong; capillary refill is less than 3 seconds on digits. Skin is pale, warm and dry. No edema noted in the lower extremities. Breasts are soft and non tender, patient asked if she could be prescribed medication to dry up breast milk, I educated patient on comfort measures and how to decrease milk production, and informed her that the medication is no longer prescribed, patient seemed receptive to information. I suggested a consult with lactation for further teaching. Patient reported pain at a level of 3 due to mild cramping and soreness (1 to 10 scale) in the abdomen and perineal area. Bowel sounds present in all four quadrants; abdomen is soft, tender and rounded. Last bowel movement 9/23/2011. Patient states that she has not began passing flatus. The bladder is non-distended and patient reports normal urination. First void was 3 hours postpartum without discomfort.

Urine is clear, with no odor. Grimace noted during gentle palpation of the fundus. The fundus is firm, center and located at the umbilicus. 2 laceration is intact with edges approximated; moderate edema noted. Patient was given ice and tucks pads for discomfort and I educated patient on perineal care. Rubra lochia was moderate with no odor. No visible hemorrhoids. Full ROM in lower extremities, with no areas of warmth, tenderness or swelling; reflexes present. Patient reports difficulty sleeping and has asked for a sleeping aid. I suggested that the grandmother help soothe the infant between feedings to allow the patient to rest. The patient has resumed a regular diet as tolerated including three meals and two snacks a day. The patient is drinking and eating well. Once the assessment was complete I refilled the patients water, put the call light within reach and placed the side rails up and made sure the bed was in the lowest, locked position.