Postpartum OB

Question 1 of 25 Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the nurse to obtain? Vital signs. Vital sign assessment is important prior to discontinuing the Lactated Ringer's because the primary IV contributes to the maintenance of cardiovascular stability, but this is not the first priority. Vaginal discharge. Expulsion of minimal bright red vaginal discharge is normal after delivery. It is difficult for the nurse to ascertain client stability merely by assessing the vaginal discharge and estimating amounts of vaginal blood loss. Copious amounts of vaginal discharge and a boggy fundus indicate the need more in-depth assessment. Uterine firmness. Oxytocin (Pitocin) is a hormone used to stimulate uterine contractions and prevent hemorrhage from the placental site. Prior to discontinuing the IV, it is most important to ensure that the uterus is contracting by assessing fundal firmness. Oral intake. Assessment of oral fluid intake is important when determining if additional IV fluids are indicated, but it is not the first priority. Submit Question 2 of 25 Marie has minimal sensation in her lower extremities, due to the effects of the epidural anesthesia. What is the priority nursing diagnosis for Marie, who is experiencing residual effects of epidural anesthesia? Risk for injury. Epidural anesthesia causes temporary loss of voluntary movement and muscle strength in the lower extremities. Serious injury could be incurred if Marie attempts to get out of bed on her own because her legs will be unable to sustain her weight. The nursing priority is to ensure her safety by implementing use of two side-rails and instructing her to not get out of bed for the first time without assistance. Impaired physical mobility. Marie's impaired physical mobility is temporary and is not likely to cause complications resulting in longterm immobility. Altered urinary elimination. This study source was downloaded by from CourseH on 08-30-2021 02:54:52 GMT -05:00 This study resource was shared via CourseH While the epidural anesthesia may temporarily inhibit Marie's ability to void voluntarily, this is usually resolved within 6 hours. Marie should be monitored for bladder fullness during the period that she is unable to sense the need to void, but this concern is secondary to client safety. Risk for infection. The lack of sensation below the waist caused by the residual effects of epidural anesthesia does not pose any real threat of infection because epidural side effects are unrelated to the mechanisms of infection transmission or development. Submit Question 3 of 25 What is the priority nursing action to address Marie's needs related to the repair of her 4th degree perineal laceration? Provide prescribed oral pain medication and stool softener. Marie has minimal sensation below her waist because of the residual effects of the epidural anesthesia. She does not need pain medication at this time. A stool softener is usually administered within 24 hours of delivery, but it is not a priority at this time. Encourage warm sitz baths 2 to 3 times daily. Soothing, warm sitz baths should be encouraged, because they increase circulation to the site and promote healing. However, sitz baths are not encouraged until the 2nd or 3rd postpartum day, after the swelling has decreased. Apply perineal ice packs consistently for the first 24 to 48 hours. Topical perineal ice packs cause local vasoconstriction, resulting in decreased swelling and tissue congestion, preventing a hematoma, as well as promoting comfort. The application of ice packs is the priority nursing action for the first 24 to 48 hours, which is the period that the tissue is most vulnerable to swelling resulting from the trauma. A hematoma formation could contribute to hypovolemia and needs to be prevented. Teach proper and frequent use of the peri-bottle. It is important for the nurse to instruct Marie in measures to prevent infection, such as frequent and proper perineal hygiene techniques during the postpartum period. However, this teaching is not a priority at this time. Submit Early detection of, and intervention for, postpartum complications promotes positive client outcomes. Postpartum protocol requires that the nurse assess Marie's vital signs, fundus, perineum, vaginal bleeding, pain, leg movement, and IV every 15 minutes for the first hour and then every hour for the next 3 hours. This study source was downloaded by from CourseH on 08-30-2021 02:54:52 GMT -05:00 This study resource was shared via CourseH Question 4 of 25 The nurse performs the first assessment upon arrival to the postpartum unit. Where would the nurse expect to palpate the fundus? 3 cm above the umbilicus. The fundus should be no higher than 2 cm above the umbilicus. 1 cm to the right of the umbilicus. The fundus should be directly above the umbilicus. If the fundus is 1 cm to the right of the umbilicus it may indicate a full bladder. 1 cm to the left of the umbilicus. The fundus should be directly above the umbilicus. 1 cm above the umbilicus. For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus. Question 5 of 25 Which action is most important for the nurse to implement immediately? Massage the fundus. Take vital signs. Increase the IV rate. Check the bladder. Submit Question 6 of 25 What is the best method for the nurse to use to obtain immediate assistance? Telephone the healthcare provider (HCP) from the client's room. Go to the nurses' station to notify the charge nurse. Activate the priority call light from the bedside. Call for help from the doorway of the client's room. Submit Question 7 of 25 The nurse has requested assistance and personnel are on their way. While waiting for help to arrive, what is the next priority action? Administer pain medication. Administer oxygen by nasal cannula. Assess for bladder distention. Increase the IV infusion rate. Submit This study source was downloaded by from CourseH on 08-30-2021 02:54:52 GMT -05:00 This study resource was shared via CourseH Question 8 of 25 The charge nurse, two staff nurses, and an unlicensed assistive personnel (UAP) rush in to assist the nurse with Marie. Which task is best delegated to the UAP during this crisis? Bring IV fluids and supplies from the supply room. Change the bed linens and bathe the client. Start O2 per nasal cannula. Obtain the vital signs and O2 saturation. The HCP is notified that Marie is hemorrhaging and has an estimated blood loss of 1,200 mL since delivery. Her blood pressure is 70/40 mmHg, pulse 120 beats/min, respirations 28 breaths/min, and O2 saturation 73%. The HCP's prescriptions include stat oxytocin (Pitocin) 10 units in each liter of normal saline to infuse at 40 milliunits (mU)/minute. The HCP also prescribes 0.2 mg methylergonovine maleate (Methergine) IM to be given immediately. The vial of oxytocin (Pitocin) is labeled 20 units/mL. The vial of methylergonovine (Methergine) is labeled 0.8 mg/mL. How many mL of oxytocin (Pitocin) should the nurse draw up in the syringe to inject into the 1000 mL bag of normal saline? (Enter numerical value only. If rounding is necessary, round to the tenth.) 0.5 Question 10 of 25 Fill in the blank How many mL of methylergonovine (Methergine) should the nurse draw up in the syringe to administer to Marie? (Enter numerical value only. If rounding is necessary, round to the hundredth.) 0.25 Which finding is most indicative that the medication is reaching a therapeutic level? Blood pressure 74/44. Heart rate 94. O2 saturation 85%. Firm fundus. Question 12 of 25 Postpartum hemorrhage is designated as blood loss in excess of 500 mL within the first 24 hours of delivery. Considering the client's history, what etiology is most likely? Perineal laceration. Retained placental parts. Uterine atony. Coagulopathy. Submit Marie is pale, weak, and anxious, but no longer disoriented. Her fundus is firm and is 1 cm above the umbilicus. She is receiving O2 per nasal cannula at 4 liters/minute and has an O2 saturation of This study source was downloaded by from CourseH on 08-30-2021 02:54:52 GMT -05:00 This study resource was shared via CourseH 88%. Her vital signs are BP 74/44 mmHg, P 116 beats/min, and R 26 breaths/min. Her bleeding has slowed considerably. The nurse asks the UAP to bathe Marie and change the bed linens. Marie tells the nurse that her husband went home to pick up their other child to bring her to the hospital. She states that she doesn't want her children to see her this way and asks the nurse to tell Mr. Wilson what has happened. Question 13 of 25 What intervention should the nurse implement to communicate the situation to Marie's husband? Ask the unit clerk to notify Mr. Wilson about Marie's change in condition, but let him know that she is going to be all right. Call Mr. Wilson from the nurses' station to inform him of his wife's status and request that he come to the hospital soon, without the other child. Dial the telephone number for Marie and hold the phone for her, allowing her to talk to her husband and explain what happened. Wait until Mr. Wilson arrives at the hospital with the other child, and talk to him before he goes in to see his wife. What should the nurse do to prepare for Marie’s blood transfusion? Select all that apply Ask the UAP to pick up the blood from the blood bank. Start an additional IV using a 16 or 18 gauge angiocath. Prime a new Y-set blood tubing using a new bag of normal saline. Monitor for fluid overload by assessing lab results, urine output, and respiratory status. Obtain a baseline set of vital signs. Question 15 of 25 What is the best thing for Marie's nurse to do? Encourage Marie to nurse the infant while proceeding with the blood administration. Delay hanging the blood for 15 to 20 minutes until Marie finishes nursing the infant. Request that the infant be brought back in an hour to give the blood time to take effect. Explain Marie's history and request that the infant is fed with formula in the nursery. Question 16 of 25 Prior to the blood transfusion, the nurse records Marie's vital signs as T 97.8° F, BP 78/50 mmHg, P 110 beats/min, and R 22 breaths/min. The blood requisition form, client identification bracelet, and blood label are checked with another nurse, and then the A negative blood transfusion is started at 75 mL/hr. Fifteen minutes after the transfusion begins, another set of vital signs is taken; T 98.5° F, BP 76/48 mmHg, P 112 beats/min, and R 22 breaths/min. Marie complains of being cold.What should the nurse do in response to these assessment findings? Decrease the rate of the transfusion to 50 mL/hr. This study source was downloaded by from CourseH on 08-30-2021 02:54:52 GMT -05:00 This study resource was shared via CourseH Stop the transfusion and call the HCP. Provide a warm blanket and continue to monitor. Compare the blood type on the blood labels with the requisition forms. Submit When the first unit of packed red blood cells (PRBCs) is infused, the nurse performs a targeted assessment. Marie's fundus remains firm and lochial flow has decreased to a small amount. Her vital signs are T 98.3° F, BP 96/58 mmHg, P 92 beats/min, and R 22 breaths/min. Her SaO2 is 92% with 3 liters of oxygen per nasal cannula. In preparation for shift change, the nurse calculates the intake and output for the past 4 hours as follows: INTAKE: Oral 720 mL IV 500 mL Blood 300 mL Total Intake 1,520 mL OUTPUT: Urine 500 mL (catheterized just prior to birth; 4 hours ago) Bleeding 1,600 mL Total Output 2,120 mL Question 17 of 25 Fill in the blankWhat is the difference in Marie's intake and output? 600 Submit Question 18 of 25 The nurse is aware that Marie's condition is stabilizing. Which nursing intervention would be most appropriate at this time? Contact respiratory therapy to obtain a blood gas to verify the (SaO2) reading. Restrict Marie's sodium intake to decrease output. Palpate Marie's bladder for fullness and catheterize if indicated. Request a prescription for hourly hemoglobin and hematocrit measurements. Submit Marie tells the nurse that she has sensation in her lower extremities, that she can move both her legs, and that she needs to use the bathroom. The nurse offers Marie the use of a bedpan or bedside commode. Marie replies that she feels slightly dizzy and would like to sit up on the bedpan rather than attempt to get out of bed right now. Marie is able to void 450 mL on the bedpan and reports that she feels she has emptied her bladder completely This study source was downloaded by from CourseH on 08-30-2021 02:54:52 GMT -05:00 This study resource was shared via CourseH Question 19 of 25 Considering Marie's history, what would be the most likely cause of Marie's headache? Oxygen administration (3 liters/nasal cannula). Epidural anesthesia. Straining during delivery. Side effect of oxytocin (Pitocin). Question 20 of 25 Considering Marie's history and acuity level, who is the best nurse to assign to Marie's care? Registered nurse (RN) who has been licensed for 9 months. This nurse is too inexperienced to be assigned to Marie's care. The nurse should be assigned to care for more stable postpartum clients. Labor and delivery nurse with 12 years of experience, who was called in to work for 4 hours until 2300. This nurse is experienced with handling the acute needs of obstetrical clients and would be a great resource for the next 4 hours in helping stabilize Marie's condition. Marie, when more stabilized, could then be reassigned at 2300. Licensed practical nurse (LPN) with 15 years of postpartum/nursery experience. The LPN, even with many years of experience, should not be assigned to care for an unstable client with acute care needs, including the transfusion of a second unit of blood. Charge nurse with 5 years of experience who oversees care during the night shift and carries 1/2 of the client assignment load until 2300. During the next 4 hours, the charge nurse will be tied up with managing the unit, making new admission assignments, handling problems, and overseeing client care. If the charge nurse is assigned to care for an unstable client with acute care needs, there is a risk that either the client's care or the unit management would be neglected. Marie's nurse gives the shift report and turns Marie's care over to the nurse who has been assigned to her care. As the nurse is preparing to leave for the evening, Marie's HCP calls, returning the page. Question 21 of 25 Who is the best person to speak with Marie's HCP? The unit clerk who answered the call. Marie's nurse, who has already given the shift report and is preparing to clock out. The charge nurse, who is leaving but is sitting at the desk finishing up some lastminute paperwork. Marie's new nurse, who is still receiving the change of shift report. Submit Question 22 of 25 Which task is best for the nurse to delegate to the UAP? Instruct Marie that she must remain in the left lateral sims position in bed. Provide peri-care so the nurse can insert the Foley catheter. This study source was downloaded by from CourseH on 08-30-2021 02:54:52 GMT -05:00 This study resource was shared via CourseH Obtain and document Marie's vital signs. Check on the status of Marie's infant and assure Marie that he is receiving good care. Question 23 of 25 Prior to administering the medications to Marie, which information should the nurse include about caffeine and sodium benzoate? Caffeine and sodium benzoate will constrict the cerebral blood vessels and decrease the headache. Caffeine and sodium benzoate will lower your blood pressure and decrease the pain. This medication will be given block the production of chemicals that cause the headache. Caffeine and sodium benzoate block the histamine production that are causing the headache. Submit Question 24 of 25 Based on this information, what is the correct nursing action? Obtain RhoGam from the blood bank, and administer it as soon as possible. Allow Marie to rest during the blood transfusion, and administer the RhoGam as prescribed at a later time. Notify the HCP and request a Coombs' positive blood test for Marie and her infant. Notify the HCP and request and hemoglobin and hematocrit be drawn on the infan An Organizational Safety IssueMarie's husband comes to the nursing station and asks for an update on Marie's condition. The nurse explains that Marie is resting while receiving her second unit of blood and that her fundus is firm, her vital signs are stable, and she was able to use the bedpan to void. She tells the husband that when Marie sat up to void, she developed a severe migraine and is now being treated for PDPH. The nurse explains this disorder and the necessary treatment. The husband becomes frustrated and storms off the unit shouting, "I can't believe you incompetent people here at this hospital! First you almost let my wife bleed to death, and now I find out that the idiot who put in the epidural catheter didn't know what he was doing! Someone is going to pay for this!" Mr. Wilson goes into Marie's room where she is breastfeeding the baby. Ten minutes later, the Infant Abduction alarm on the unit is activated, and the nurse sees Mr. Wilson walking out the door with an infant in his arms.What priority action should the nurse implement? Notify the security personnel and direct all staff to report to their assigned exit in the hospital. Document the observation in the client record and submit an incident report to risk management. Notify the healthcare provider about the husband's reaction and behavior. Request that pastoral care personnel locate the husband and discuss the issues. Submit This study source was downloaded by from CourseH on 08-30-2021 02:54:52 GMT -05:00 This study resource was shared via CourseH Powered by TCPDF ()