Clinical Judgment Care Planning

Patient first baby delivery

Type of delivery: SVD

Patient blood type: A+

Rubella: Immune

Hepatitis B: reactive

GBS status: positive 

Hemoglobin:pre-delivery: 12.4 post-delivery: 10.8

Vital signs:Temp: 97.4, Respiration: 20, BP: 102/57

Uterus: firm, midline, one finger under the umbilicus

The patient is breastfeeding her baby 

Medical surgical history: Breast reduction surgery 

Medical history: Palpitations

Family history: High blood pressure 

No sign of UTI

Lochia: No clots

Homan’s: no humans sign 

Abnormals: 

Lump or mass in the breast

Viability of pregnancy

Encounter to determine fetal 

Migraine without aura