Answer Happy

1. What is the admitting Diagnosis to the patient and her social history?
2. Can you do a FDAR charting to this patient.
L.S., a 29-yr-old G2P1 client was on her 38th week of pregnancy when admitted in spontaneous labor at 5:00 p.m. of August 11, 2019, in a local maternity hospital. Her first pregnancy was without any complications. However, in this second pregnancy she was treated with ritodrine, from 29 to 37 weeks gestation due to premature contractions. Her initial examination revealed that the cervix was 1 cm dilated with complete effacement. The fetus presented with a vertex position in Hodge II. Vital signs were: Temp. 37°C, PR= 82/min, RR= 20/min BP= 120/80 Admitting Orders were: DSLR 1L to run for 12 hours NPO temporarily CBC, HBsAg, Blood typing, Cross-matching Tunit FWB CBR W/O BRP Monitor and record FHT, contractions Refer for progress of labor While in the Labor Room, a first spontaneous hypertonic and prolonged contraction occurred at 7:40 p.m. with accompanying prolonged deceleration. The fetal heart rate went down to 54 beats/min for 8 min. The attending physician immediately made the following orders: • Place the patient in a side-lying position. • Monitor FHT and contractions closely The FHR returned to 110 and 120 /bpm quickly with a good beat-to-beat variation. At 9.20 p.m. another spontaneous hypertonic contraction occurred with a prolonged deceleration which normalized rapidly after putting the patient again in the side position. The cervix was still 1 cm dilated and amniotomy was performed, revealing clear amniotic fluid. The planned fetal pH determination was not performed because of the clear amniotic fluid and the rapid recovery of the FHR. Vital signs were: BP: 130/90, PR= 89/min. RR= 22/min, T=37°C Another order was made at this point: • Maintain patient on side lying position • 02 inhalation via face mask PRN • Mgs04 20% 2g, slow iv push "stat" • Monitor vital signs • Prepare for possible caesarean section But because of the good beat-to-beat variation, good fetal movements and the quick disappearance of the deceleration in the side position, it was decided that a caesarian section should not be performed yet. One hour later the contractions became regular but were consistently hypertonic and prolonged. Every 10-15 minute, a contraction lasting for 5-7 min occurred. The cervix progressed quickly from 6 cm to full dilatation within 30 min and at 3.00 a.m. a healthy baby boy weighing 3250 g, was born, Apgar 9 at 1 min. The placenta was out at 3:05 am, weighed 500 g and was visibly normal and complete