Quality and Safety Education for Nurses



NRSG 422- High Risk Labor & Delivery Simulation Clinical

Spring 2015 0830-1600

Agenda

0830- Meet in LRC Room 19

Discuss plan for day, outcomes and expectations

0845- Brief review:

-Normal perfusion in antepartum/intrapartum/postpartum

-reassuring vs. non-reassuring FHT

- Intrapartum Management and Resuscitation

- NRP

-Review of SBAR & TeamSTEPPS

-View youtube videos

• Placenta Previa



• Placenta abruptio



0925- Bathroom break

0930-1045- Break into assigned groups of 4 (Group 1 remain in Room 19 and work on exemplars & case study, Group 2 to skills lab)

1045-1055- debriefing

1055- 5 min break, switch groups

1100-1220- Break into assigned groups of 4 (Group 2 in Room 19 and work on exemplars & case study, Group 1 to skills lab)

1220-1230- debriefing

1230-1300- Lunch (both groups)

1300-1400 Group 2 to Noelle room for next scenario

1400-1500 Group 1 to Noelle room for next scenario

1500-1600

• Debrief

• Complete paperwork and turn in

• NCLEX questions with clickers

• Fetal demise discussion, perinatal hospice

o Do’s/Don’ts of helping families through grief

o Youtube videos:

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Skills lab/simulation (Scenario 1 in morning with more guidance)

4 IV start stations (4 arms) with all IV start equipment and IV bags (will need 8 bags, 8 sets of tubing)

All students will start IV and walk through admission process of patient. (4 patients in beds) Will go through assessments, lab work, SBAR, etc. will go through preeclampsia/high risk pregnancy scenario with guidance

Preeclampsia scenario taken from QSEN website, “Unfolding Case Study-Annie Foster”

Scenario 2 in afternoon- less guidance

Postpartum Hemorrhage and High risk neonate

Noelle simulator in bed, post partum. Puts call light on and complains of vague symptoms of not feeling well. “Can’t put her finger on it but didn’t feel this way after having her last baby.” Have 1 student play primary nurse. If that student needs help can utilize classmates. Eventually student should pull sheet away to assess fundus and will find large amount of blood on chux pad. Instructor guides as necessary asking “What if this happens?” “What could be cause of PPH?” Patient continues to deteriorate and all students jump in and complete assessments, assign duties, and discuss roles.

422 Simulation Clinical skills check offs

1. IV Start

2. Program primary and secondary IV on IV pump, carpuject use, adding med to IV bag

3. Foley insertion

4. Deep Tendon Reflexes

5. Clonus, Homan’s

6. Intrapartum resuscitation (roll patient to left lateral side, O2 on, IV wide open, Pitocin off)

7. Fundal checks

8. Cervical check

9. Neonatal resuscitation (basic)

Other OB emergencies demonstrated/discussed by instructor

1. Shoulder dystocia (turtle sign, McRoberts maneuver, Zavanelli, Suprapubic pressure, erbs palsy, brachial plexus injury

2. Prolapsed cord

3. Precipitous labor and delivery (care of mother and newborn when MD not present)

NRSG 422 High Risk OB Simulation Clinical NCLEX review

1. The nurse working in a women’s clinic is returning telephone calls. Which client should the nurse contact first?

a. Answer 2

i. A severe headache is a symptom of pre-eclampsia; because this is the client’s first pregnancy, she requires further eval. The other client’s are not priority over a client who has an acute complaint

2. A client 36 weeks pregnant comes to the clinic and has a blood pressure 160/102, 4+ proteinuria, and edematous hands and feet. Which data should the nurse assess next?

a. Answer 3

i. The client’s s/s suggest pregnancy-induced HTN, which if worsening would cause hyperreflexia. Therefore, the nurse should assess the client’s DTR (range 0-4, with 2+ being normal.) The heart rate, urine spec grav, and activity tolerance would not yield information pertinent to possible PIH.

3. The client is admitted to the labor and delivery unit diagnosed with PIH and has pre-eclampsia. Which intervention should the nurse implement first?

a. Answer 1

i. The nurse’s first intervention is to prevent the client from having a seizure during the delivery of her baby; therefore, starting Mag Sulfate IV is priority. Then the nurse should check the BP and notify the nursery. The client’s vision is not assessed (Snellen chart) during L&D.

4. The client at 40 weeks gestation has just delivered a stillborn infant. Which intervention should the nurse implement first?

a. Answer 4

i. The mother should be allowed to hold her infant in order to facilitate the grieving process and to say good-bye. This is the nurse’s first intervention. The client should not be placed on the PP where babies are crying and happy people are reminders of her loss.

5. The client in labor is showing late decelerations on the fetal monitor. Which intervention should the nurse implement first?

a. Answer 3

i. The left lateral position will improve placental blood flow and oxygen supply to the fetus; therefore, that is the nurse’s first intervention. Then, the nurse should calm the mother, notify the HCP, and prepare for an emergency c/s.

6. The nurse in the labor and delivery department is caring for a client who is having bright red painless bleeding, and the fetal heart rate is 100. Which client problem is priority?

a. Answer 3

i. The client is exhibiting signs of placenta previa, and a decreased fetal heart rate indicates a compromised fetus. These problems will quickly lead to death of the fetus; therefore, this is the priority problem. The mother is hemorrhaging it is an actual problem, not a risk problem.

7. The labor and delivery nurse is performing a vaginal examination and has assessed a prolapsed cord. Which intervention should the nurse implement?

a. Answer 3

i. The nurse does not want the fetus to be delivered if the cord is compressed between the baby’s head and the cervical os. Therefore, the nurse must attempt to stop the delivery by telling the client not to push. The client should be placed in the Trendelnburg position and be prepared for and emergency c/s.

8. The mother has just delivered the newborn. The newborn has a pulse of 120, a lusty cry, a flexed body, and spontaneous movements and responds promptly to suctioning. Which APGAR score should this newborn receive?

a. Answer 4

i. This infant meets the criteria for an APGAR of 10, which indicates the infant was born healthy.

9. The nurse is administering medications to clients on a postpartum floor. Which medication should the nurse question administering?

a. Answer 4

i. Restoril is a pregnancy category X drug which means it is teratogenic. Any medication the client tatkes can be excreted in the breast milk, affecting the infant. The client with a negative titer needs rubella vaccine; the flu vaccine is contraindicated in someone with allergy to eggs, not tomatoes, and mag sulfate is given up to 24 hours after delivery.

10. The CNA tells the nurse the postpartum client has T 98.2, P 124, R 30, and BP 88/60. Which action should the nurse implement first?

a. Answer 2

i. Whenever anyone else reports information to the nurse, the nurse must assess the client in person; this client’s vital signs indicate hypovolemic shock.

11. Which newborn infant would warrant immediate intervention by the nurse?

a. Answer 2

i. The infant who is jittery and irritable may have hypoglycemia and should be assessed immediately by the nurse. The normal heart rate for a newborn is 120-160 beats per minute; 2 ounces of formula is and adequate feeding for a 12 hour old newborn, and the newborn should pass meconium.

12. A Nurse is caring for a PP patient. The nurse should understand that which of the following findings are the earliest indication of hypovolemia caused by hemorrhage?

a. Answer 1

i. A rising pulse and decreasing BP are often the first indicators of inadequate blood volume.

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