Fatime Sanogo is a 23-year-old G1P0 female from Mali. She arrived at the mother/baby unit 30 minutes ago, following a spontaneous vaginal birth.

When she was admitted to labor and delivery yesterday at 0600 hours, she was at 41 4/7 weeks of gestation, her cervix was dilated 1 cm, 50% effaced, and at -2 station. Labor began shortly after at 0800 hours, and she did not receive any pain medication during labor. At 0100 hours today, she progressed to complete dilatation. She began to actively push at 0215 hours.

After a prolonged second stage, where both mother and fetus were stable, she delivered a girl at 0535 hours. The baby was stable with Apgar scores of 9 and 9, and weight of 9 lb 0 oz. Fatime got a second-degree perineal laceration in the course of delivery; this has been repaired. The placenta was delivered spontaneously at 0550 hours by Dr. Schultz, with some bleeding afterward. At arrival in the mother/baby unit, the fundus was firm, midline, at umbilicus, and lochia was dark red and small.

Fatime received some pain medication just before arrival. Her breasts are soft with no nipple damage, and labor and delivery reports that breastfeeding is going fine. A saline lock has been placed in her forearm. She was just up to the bathroom and couldn’t void. Right now, Fatime and the baby are dozing, and the father is sitting at the bedside. Fatime does not speak English fluently, as she has only been in the country for 7 months.

Documentation Assignments

1. Document your initial assessment data for Ms. Sanogo, including vital signs, fundal assessment (consistency, position, location), lochia assessment (amount, color, odor, consistency), and pain (location, quality, severity).

2. Document the medication(s) that you administered and evaluate each drug’s effectiveness.

3. Document your situation-background-assessment-recommendation (SBAR) communication to Ms. Sanogo’s provider during this simulation activity.

4. Document the nursing interventions carried out during this simulation, including the time for each intervention, and evaluate the effectiveness of these measures in resolving the problem.

5. Document the education that was provided to Ms. Sanogo during this scenario.

6. Record the communication that was expressed to Ms. Sanogo’s husband.

From vSim for Nursing | Maternity. © Wolters Kluwer Health.