Caring For a New Mother

C.E is a 23 year old Hispanic female who came to the Hospital on April 12th at eight pm for the reason that she was experiencing contractions at less than ten minutes apart as a result of pregnancy, she reported her pain at 8/10 patients vitals were taken upon admission, her blood pressure was elevated 132/84, patients effacement was at 50% upon admission C.E is a gravida 1, para 1(G:1/P:1), her last menstrual period was on 7/5/13 When C.E came to the hospital her fundal height was 39cm and her estimated date of confinement was 4/12/2014. During pregnancy C.E had no complications and the fetus presented no abnormalities she reported taking prenatal vitamins, and a calcium supplement. C.E had a NSVD (normal spontaneous vaginal delivery) at 0938 April 14th to a healthy female baby C.E was in labor for 7 hours. Patient has an intact perineum; placenta was delivered spontaneously and remained intact, after birth both mother and baby remained in a stable condition.

History of present illness:

40 gestational weeks, term baby, no complications, came to hospital due to contractions and effacement of cervix.

Admitting diagnosis:

C.E came to the hospital because she was experiencing contractions that did not cease after changing position, occurred at regular intervals and steadily increased in strength, which are experienced after the onset of labor.

Physical Assessment (upon admission)

-reparatory: RR was 20, labored due to pain, clear bilaterally

-cardiovascular: BP 132/84, no history of HNT

GI: no bowel sounds present, patient was kept NPO

Neurologic: Pt alert and oriented x4. Pt is fully awake and reports having pain 8/10

Genitourinary: patient reported urinating before onset of pain

Integumentary: Skin is warm, ...

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