HESI RN EXIT CASE STUDY: POSTPARTUM II
UPDATED AND REVISED IN 2024-2025 DECEMBER
Prior to discontinuing the IV oxytocin (Pitocin), which
assessment is most important for the nurse to obtain? -
ANSWER->C) Uterine firmness.
Hormone used to stimulate uterine contractions and prevent
hemorrhage from the placental site.
Mari has minimal sensation in her lower extremities, die to the
effects of the epidural anesthesia. What is the priority nursing
diagnosis for Mari, who is experiencing residual effects of
epidural anesthesia? - ANSWER->A) Risk for injury.
Causes temporary loss of voluntary movement and muscle
strength in the lower extremities. Serious injury could be
incurred if Mari attempts to get out of bed on her own because
her legs will be unable to sustain her weight.
What is the priority nursing actions to address Mari's needs
related to the repair of her 4th degree perineal laceration? -
ANSWER->C) Apply perineal ice packs consistently for the first
24 to 48 hours.
Cause local vasoconstriction, resulting in decreased swelling
and tissue congestion, preventing a hematoma, as well as
prmoting comfort. 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.
The nurse performs the first assessment upon arrival to the
postpartum unit. Where would the nurse expect to palpate the
fundus? - ANSWER->D) 1 cm above the umbilicus.
For the first 12 hours, the fundus should be 1 to 2 cm above the
umbilicus.
Which action is most important for the nurse to implement
immediately? - ANSWER->A) Massage the fundus.
Since a boggy fundus is the ost likely reason for this client's
hemorrhaging, massaging the fundus is the most important
intervention. The nurse should also call for assistance die to the
amount of blood that has pooled unde the client.
What is the best method for the nurse to use to obtain
immediate assistance? - ANSWER->C) Activate the priority call
light from the bedside.
The priority call light signals to the entire nursing unit that a
client is in crisis. All personnel available will respond to the
distress signal.
UPDATED AND REVISED IN 2024-2025 DECEMBER
Prior to discontinuing the IV oxytocin (Pitocin), which
assessment is most important for the nurse to obtain? -
ANSWER->C) Uterine firmness.
Hormone used to stimulate uterine contractions and prevent
hemorrhage from the placental site.
Mari has minimal sensation in her lower extremities, die to the
effects of the epidural anesthesia. What is the priority nursing
diagnosis for Mari, who is experiencing residual effects of
epidural anesthesia? - ANSWER->A) Risk for injury.
Causes temporary loss of voluntary movement and muscle
strength in the lower extremities. Serious injury could be
incurred if Mari attempts to get out of bed on her own because
her legs will be unable to sustain her weight.
What is the priority nursing actions to address Mari's needs
related to the repair of her 4th degree perineal laceration? -
ANSWER->C) Apply perineal ice packs consistently for the first
24 to 48 hours.
Cause local vasoconstriction, resulting in decreased swelling
and tissue congestion, preventing a hematoma, as well as
prmoting comfort. 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.
The nurse performs the first assessment upon arrival to the
postpartum unit. Where would the nurse expect to palpate the
fundus? - ANSWER->D) 1 cm above the umbilicus.
For the first 12 hours, the fundus should be 1 to 2 cm above the
umbilicus.
Which action is most important for the nurse to implement
immediately? - ANSWER->A) Massage the fundus.
Since a boggy fundus is the ost likely reason for this client's
hemorrhaging, massaging the fundus is the most important
intervention. The nurse should also call for assistance die to the
amount of blood that has pooled unde the client.
What is the best method for the nurse to use to obtain
immediate assistance? - ANSWER->C) Activate the priority call
light from the bedside.
The priority call light signals to the entire nursing unit that a
client is in crisis. All personnel available will respond to the
distress signal.
