HESI RN CASE STUDY POSTPARTUM EXAM WITH CORRECT
ANSWERS
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the nurse to obtain? -
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correct answer C) Uterine firmness.
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Hormone used to stimulate uterine contractions and prevent hemorrhage from the placental site.
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Mari has minimal sensation in her lower extremities, die to the effects of the epidural anesthesia. What is the
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priority nursing diagnosis for Mari, who is experiencing residual effects of epidural anesthesia? - correct
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answer A) Risk for injury. t t t t
Causes temporary loss of voluntary movement and muscle strength in the lower extremities. Serious injury
t t t t t t t t t t t t t t t
could be incurred if Mari attempts to get out of bed on her own because her legs will be unable to sustain her
t t t t t t t t t t t t t t t t t t t t t t t
weight.
What is the priority nursing actions to address Mari's needs related to the repair of her 4th degree perineal
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laceration? - correct answer C) Apply perineal ice packs consistently for the first 24 to 48 hours.
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Cause local vasoconstriction, resulting in decreased swelling and tissue congestion, preventing a hematoma,
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as well as prmoting comfort. Application of ice packs is the priority nursing action for the first 24 to 48 hours,
t t t t t t t t t t t t t t t t t t t t t
which is the period that the tissue is most vulnerable to swelling resulting from the trauma. A hematoma
t t t t t t t t t t t t t t t t t t
formation could contribute to hypovolemia and needs to be prevented.
t t t t t t t t t
, The nurse performs the first assessment upon arrival to the postpartum unit. Where would the nurse expect to
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palpate the fundus? - correct answer D) 1 cm above the umbilicus.
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For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus.
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Which action is most important for the nurse to implement immediately? - correct answer A) Massage the
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fundus.
Since a boggy fundus is the ost likely reason for this client's hemorrhaging, massaging the fundus is the most
t t t t t t t t t t t t t t t t t t t
important intervention. The nurse should also call for assistance die to the amount of blood that has pooled
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unde the client. t t
What is the best method for the nurse to use to obtain immediate assistance? - correct answer C) Activate the
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priority call light from the bedside. t t t t t
The priority call light signals to the entire nursing unit that a client is in crisis. All personnel available will
t t t t t t t t t t t t t t t t t t t t
respond to the distress signal. t t t t
The nurse has requested assistance and personnel are on their way. While waiting for help to arrive, what is the
t t t t t t t t t t t t t t t t t t t
next priority action? - correct answer C) Assess for bladder distention.
t t t t t t t t t t t
The client is 2 hours post-delivery with an IV infusion at 125 mL/hour, which can contribute to diuresis. A
t t t t t t t t t t t t t t t t t t t
distended bladder impedes uterine contraction and contributes to excesive bleeding. After the fundus is
t t t t t t t t t t t t t t
massaged, the bladder should be checked for distention. t t t t t t t
The charge nurse, two staff nurses and an unlicensed assistive personnel (UAP) rush in to assist the nurse with
t t t t t t t t t t t t t t t t t t t
Mari. Which task is best delegated to the UAP during the crisis? - correct answer D) Obtain the vital signs and O2
t t t t t t t t t t t t t t t t t t t t t t
saturation.
Both are within the scope of practice for the UAP, and the nurse should interpret thses findings as indications
t t t t t t t t t t t t t t t t t t t
of hypovolemia due to blood loss and should also be report the findings to the HCP.
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ANSWERS
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the nurse to obtain? -
t t t t t t t t t t t t t t t t t t
correct answer C) Uterine firmness.
t t t t
Hormone used to stimulate uterine contractions and prevent hemorrhage from the placental site.
t t t t t t t t t t t t
Mari has minimal sensation in her lower extremities, die to the effects of the epidural anesthesia. What is the
t t t t t t t t t t t t t t t t t t t
priority nursing diagnosis for Mari, who is experiencing residual effects of epidural anesthesia? - correct
t t t t t t t t t t t t t t t
answer A) Risk for injury. t t t t
Causes temporary loss of voluntary movement and muscle strength in the lower extremities. Serious injury
t t t t t t t t t t t t t t t
could be incurred if Mari attempts to get out of bed on her own because her legs will be unable to sustain her
t t t t t t t t t t t t t t t t t t t t t t t
weight.
What is the priority nursing actions to address Mari's needs related to the repair of her 4th degree perineal
t t t t t t t t t t t t t t t t t t t
laceration? - correct answer C) Apply perineal ice packs consistently for the first 24 to 48 hours.
t t t t t t t t t t t t t t t t
Cause local vasoconstriction, resulting in decreased swelling and tissue congestion, preventing a hematoma,
t t t t t t t t t t t t t
as well as prmoting comfort. Application of ice packs is the priority nursing action for the first 24 to 48 hours,
t t t t t t t t t t t t t t t t t t t t t
which is the period that the tissue is most vulnerable to swelling resulting from the trauma. A hematoma
t t t t t t t t t t t t t t t t t t
formation could contribute to hypovolemia and needs to be prevented.
t t t t t t t t t
, The nurse performs the first assessment upon arrival to the postpartum unit. Where would the nurse expect to
t t t t t t t t t t t t t t t t t
palpate the fundus? - correct answer D) 1 cm above the umbilicus.
t t t t t t t t t t t t
For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus.
t t t t t t t t t t t t t t t
Which action is most important for the nurse to implement immediately? - correct answer A) Massage the
t t t t t t t t t t t t t t t t t
fundus.
Since a boggy fundus is the ost likely reason for this client's hemorrhaging, massaging the fundus is the most
t t t t t t t t t t t t t t t t t t t
important intervention. The nurse should also call for assistance die to the amount of blood that has pooled
t t t t t t t t t t t t t t t t t t
unde the client. t t
What is the best method for the nurse to use to obtain immediate assistance? - correct answer C) Activate the
t t t t t t t t t t t t t t t t t t t t
priority call light from the bedside. t t t t t
The priority call light signals to the entire nursing unit that a client is in crisis. All personnel available will
t t t t t t t t t t t t t t t t t t t t
respond to the distress signal. t t t t
The nurse has requested assistance and personnel are on their way. While waiting for help to arrive, what is the
t t t t t t t t t t t t t t t t t t t
next priority action? - correct answer C) Assess for bladder distention.
t t t t t t t t t t t
The client is 2 hours post-delivery with an IV infusion at 125 mL/hour, which can contribute to diuresis. A
t t t t t t t t t t t t t t t t t t t
distended bladder impedes uterine contraction and contributes to excesive bleeding. After the fundus is
t t t t t t t t t t t t t t
massaged, the bladder should be checked for distention. t t t t t t t
The charge nurse, two staff nurses and an unlicensed assistive personnel (UAP) rush in to assist the nurse with
t t t t t t t t t t t t t t t t t t t
Mari. Which task is best delegated to the UAP during the crisis? - correct answer D) Obtain the vital signs and O2
t t t t t t t t t t t t t t t t t t t t t t
saturation.
Both are within the scope of practice for the UAP, and the nurse should interpret thses findings as indications
t t t t t t t t t t t t t t t t t t t
of hypovolemia due to blood loss and should also be report the findings to the HCP.
t t t t t t t t t t t t t t t
