Shadow Health Non-Reassuring Fetal Status Subjective Data 2024/2025

lOMoAR cPSD| 10631844

Shadow Health Non-Reassuring Fetal Status Subjective Data

lOMoAR cPSD| 10631844

| Shadow Health® │ Digital Clinical Experiences™ from Elsevier

Focused Exam: Non-Reassuring Fetal Status Results | Completed NURS 438: Patient-Centered Care: Childbearing Family Fall 2022, NURS 438 Return to Assignment (/assignments/673643/)

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Overview

Subjective Data Collection: 28 of 34 (82.4%)

Transcript Subjective Data Collection Hover To Reveal...

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Hover over the Patient Data items below to reveal important information, including Pro Tips and Example Questions.

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Objective Data Collection Education & Empathy Documentation Care Plan Intervention Activity

Category

Scored Items

Student Survey

Patient Data Not Scored

Experts selected these topics as essential components of a strong, thorough interview with this patient.

A combination of open and closed questions will yiel better patient data. The following details are facts of t patient's case.

Patient Status

Asked about patient's needs

Reports needing support person with her Reports partner went to meet patient's mother

Patient Comfort

Asked about patient's comfort

Reports current position is comfortable

Asked about patient's symptoms

Reports dull contraction pain Reports feeling contractions starting in upper abdomen

Followed up on pain

Reports contraction pain 5 out of 10

Asked about relieving factors

Reports using "yoga breathing" during contractions

lOMoAR cPSD| 10631844

| Shadow Health® │ Digital Clinical Experiences™ from Elsevier Reports movement helps alleviate pain

Review Birth Plan

Asked about birth plan

Denies wanting to use pain medication Reports desire to use birthing tub Reports desire for support person to be present at delivery

Followed up on pain management preferences

Reports desire to use essential oils during active labor and delivery Reports desire to use "yoga breathing" during active labor and delivery Reports plan to use position changes during active labor and delivery

Followed up on support system

Reports support person is partner, Javier

Asked about infant care

Reports planning to breastfeed

Asked about contraction time

Reports contractions 5 minutes apart

Intranatal History

Reports contractions 1 minute in duration

Asked about current pregnancy

Reports current pregnancy is overdue (40 weeks 2 days) Reports water has broken

Followed up on water breaking

Reports water broke in OB office during appointment Reports amniotic fluid clear Reports amniotic fluid odorless Reports OB appointment was to discuss inducing labor

Asked how she was transported to the hospital

Reports partner drove her from OB office to hospital

Asked how long she has been in labor

Reports laboring for 7 hours

Asked about prenatal care

Reports taking prenatal vitamins Reports receiving prenatal care starting at 8 weeks

Asked status of baby

Reports baby moving daily

Asked about vaginal discharge

Reports vaginal discharge Reports vaginal discharge is clear Denies vaginal bleeding Denies unusual odor for vaginal discharge

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lOMoAR cPSD| 10631844

| Shadow Health® │ Digital Clinical Experiences™ from Elsevier Reproductive History

Asked about previous pregnancies

Reports two previous pregnancies

Followed up on first pregnancy

Reports first pregnancy was 39 weeks Reports delivering healthy baby boy Reports she was in labor for 17 hours Reports first birth was vaginal Denies use of pain medication during first birth

Followed up on second pregnancy

Reports second pregnancy was 40 weeks Reports delivering healthy baby girl Reports she was in labor for 8 hours Reports second birth was vaginal Denies use of pain medication during second birth

Asked about pregnancy complications

Denies pregnancy complications Denies sudden weight gain

Social History

Asked about home life

Reports longterm partner, Javier Reports one son, Junior Reports one daughter, Genesis

Followed up on children

Reports Junior is 10 years old Reports Genesis is 5 years old Reports children are staying with paternal grandparents

Asked about substance use

Denies illicit substance use Denies alcohol use Denies tobacco use

Past Medical History

Asked about preexisting conditions

Denies diabetes Denies hypertension

Asked about allergies

Denies allergies

Asked about past hospitalizations

Reports only hospitalized for past pregnancies

Asked about anesthesia

Denies complications with anesthesia

Asked about patient's home medication

Denies taking prescription medications

Home Medication

Reports taking herbal supplements

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lOMoAR cPSD| 10631844

| Shadow Health® │ Digital Clinical Experiences™ from Elsevier Review of Relevant Systems

Asked about gastrointestinal system

Denies nausea Denies indigestion Denies sharp stomach pain

Asked about urinary system

Denies needing to urinate

Asked about respiratory system

Denies shortness of breath

Asked about neurological system

Denies dizziness Denies having headache Denies vision changes

Asked about cardiovascular system

Denies cardiovascular issues

Comments If your instructor provides individual feedback on this assignment, it will appear here.

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