Clinical Judgment Care Planning

Learning Goal: I’m working on a nursing report and need support to help me learn.

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

Homans: no humans sign


Lump or mass in the breast

Viability of pregnancy

Encounter to determine fetal

Migraine without aura

{you can made up some more information on the care plan as long they are making sense }