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Shadow Health Assessment

Luna Morales — Non-Reassuring Fetal Status — Focused Exam

Complete Shadow Health Focused Exam: Non-Reassuring Fetal Status for Luna Morales. Pregnant woman in early labour presenting with non-reassuring fetal heart rate patterns. Full assessment covering FHR strip interpretation, maternal repositioning, oxygen administration, IV fluid bolus, SBAR handoff to Preceptor Diana and Care Plan. Used in maternity and obstetric nursing programs.

Non-Reassuring FHREarly LabourFHR Strip InterpretationSBAR Handoff
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Clinical Overview

Luna Morales — Non-Reassuring Fetal Status — Focused Exam

Luna Morales is a pregnant woman in early labour presenting with non-reassuring fetal status. This focused exam tests your ability to recognise abnormal fetal heart rate patterns, initiate appropriate nursing interventions and communicate urgently using SBAR to Preceptor Diana.

The subjective assessment covers the history of the presenting illness — onset of labour, contraction frequency and duration, rupture of membranes status, fetal movement perception, pain level and any relevant obstetric history. A full health history is gathered including gravida/para status, gestational age, prenatal care, group B strep status and any complications this pregnancy.

The objective assessment focuses on fetal heart rate monitoring interpretation — identifying the non-reassuring pattern (late decelerations, variable decelerations or prolonged deceleration), baseline FHR, variability and accelerations. Maternal vital signs, contraction pattern and cervical status are also documented.

Nursing interventions for non-reassuring fetal status include: lateral repositioning (left lateral preferred), supplemental oxygen via non-rebreather mask, IV fluid bolus to correct possible hypotension, discontinuing oxytocin if infusing, and notifying the provider immediately. All interventions and patient responses are documented in the EHR.

The SBAR handoff to Preceptor Diana covers: Situation (non-reassuring FHR pattern identified), Background (obstetric history, current labour status), Assessment (FHR findings, maternal status, interventions performed), Recommendation (urgent evaluation, possible delivery planning).

Primary Diagnosis: Non-reassuring fetal status in early labour — nursing interventions initiated, SBAR handoff completed
What is included in each document?
  • Full focused exam interview transcript
  • Labour history — contractions, ROM, fetal movement, GBS status
  • FHR strip interpretation — pattern identification
  • Non-reassuring fetal status — late/variable decelerations documented
  • Nursing interventions — repositioning, O2, IV bolus documented
  • Maternal vital signs and contraction assessment
  • Therapeutic communication — education and empathy
  • SBAR handoff to Preceptor Diana — complete
  • Care Plan — non-reassuring fetal status management