HESI RN EXIT CASE STUDY: POSTPARTUM UPDATED
AND REVISED IN 2024-2025 DECEMBER
Meet the Client: Marie Wilson - ANSWER->Marie Wilson is a 28-year-
old client who is gravida 2, para 2, and is transferred to the postpartum
unit 1 hour after delivery of a 8 lb, 1 oz female. She was in labor for 16
hours and forceps were used to assist with the delivery. Marie was
given an epidural for anesthesia that was effective. The labor and
delivery nurse reported that Marie had a 4th degree laceration and her
pain was currently at a 3 out of 10 scale. Her vital signs were stable and
she was catheterized for 500 mL of light yellow urine just prior to
delivery. Mr. Wilson was at the bedside for delivery and appeared
supportive.
Assessment - ANSWER->A 1, 000 mL bag of Lactated Ringer's solution
containing 10 units of oxytocin (Pitocin) is infusing via an 18 gauge
peripheral IV in the LFA at 125 mL/hr, with 300 mL remaining in the
bag. The IV is patent, without redness or swelling, and can be
discontinues when the bag's infusion is complete.
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is
most important for the nurse to obtain? - ANSWER->uterine firmness
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 mins. for the first hour and then
every hour for the next 3 hours. - ANSWER->
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? -
ANSWER->Risk for injury
The nurse performs the first assessment upon arrival to the postpartum
unit. Where would the nurse expect to palpate the fundus? - ANSWER-
>1 cm above the umbilicus
What is the priority nursing action to address Marie's needs r/t the
repair of her 4th degree perineal laceration? - ANSWER->Apply perineal
ice packs consistently for the first 24 to 48 hours.
Postpartum Crisis - ANSWER->Fifteen minutes after the initial
assessment, the nurse finds Marie disoriented and lying on her back in
a pool of vaginal blood, with the sheets beneath her saturated with
blood.
Which action is most important for the nurse to implement
immediately? - ANSWER->Massage the fundus
What is the best method for the nurse to use to obtain immediate
assistance? - ANSWER->Activate the priority call light from the bedside.
The nurse has requested assistance and personnel are on their way.
While waiting for help to arrive, what is the next priority action? -
ANSWER->Assess for bladder distention
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? - ANSWER->Obtain VS and
SpO2
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 mm
AND REVISED IN 2024-2025 DECEMBER
Meet the Client: Marie Wilson - ANSWER->Marie Wilson is a 28-year-
old client who is gravida 2, para 2, and is transferred to the postpartum
unit 1 hour after delivery of a 8 lb, 1 oz female. She was in labor for 16
hours and forceps were used to assist with the delivery. Marie was
given an epidural for anesthesia that was effective. The labor and
delivery nurse reported that Marie had a 4th degree laceration and her
pain was currently at a 3 out of 10 scale. Her vital signs were stable and
she was catheterized for 500 mL of light yellow urine just prior to
delivery. Mr. Wilson was at the bedside for delivery and appeared
supportive.
Assessment - ANSWER->A 1, 000 mL bag of Lactated Ringer's solution
containing 10 units of oxytocin (Pitocin) is infusing via an 18 gauge
peripheral IV in the LFA at 125 mL/hr, with 300 mL remaining in the
bag. The IV is patent, without redness or swelling, and can be
discontinues when the bag's infusion is complete.
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is
most important for the nurse to obtain? - ANSWER->uterine firmness
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 mins. for the first hour and then
every hour for the next 3 hours. - ANSWER->
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? -
ANSWER->Risk for injury
The nurse performs the first assessment upon arrival to the postpartum
unit. Where would the nurse expect to palpate the fundus? - ANSWER-
>1 cm above the umbilicus
What is the priority nursing action to address Marie's needs r/t the
repair of her 4th degree perineal laceration? - ANSWER->Apply perineal
ice packs consistently for the first 24 to 48 hours.
Postpartum Crisis - ANSWER->Fifteen minutes after the initial
assessment, the nurse finds Marie disoriented and lying on her back in
a pool of vaginal blood, with the sheets beneath her saturated with
blood.
Which action is most important for the nurse to implement
immediately? - ANSWER->Massage the fundus
What is the best method for the nurse to use to obtain immediate
assistance? - ANSWER->Activate the priority call light from the bedside.
The nurse has requested assistance and personnel are on their way.
While waiting for help to arrive, what is the next priority action? -
ANSWER->Assess for bladder distention
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? - ANSWER->Obtain VS and
SpO2
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 mm
