HESI Patient Review: Postpartum.Perfect
revision material. You got this champ!
- Correct Answers-The client is gravida 2, para 2 and is transferred to the postpartum unit 1
hour after delivery of a 8 lb, 1 oz infant. She was in labor for 16 hours and forceps were used to
assist with the delivery. The client was given an epidural for anesthesia that was effective. The
labor and delivery nurse reported that the client 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 4 hours ago. Her spouse was at the bedside for delivery and appeared
supportive.
Prior to discontinuing the IV oxytocin, which assessment is most important for the nurse to
obtain? - Correct Answers-Uterine firmness
Rationale: Oxytocine 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.
Assessment: A 1,000 mL bag of Lactated Ringer's solution containing 10 units of oxytocin is
infusing via an 18 guage peripheral IV in the left forearm at 125 mL per hour, with 300 mL
remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued
when this bag's infusion is complete. - Correct Answers-
The postpartum client has minimal sensation in her lower extremities, due to the effects of the
epidural anesthesia. What is the priority nursing concern for this client? - Correct Answers-Fall
Risk
Rationale: Epidural anesthesia causes temporary loss of voluntary movement and muscle
strength in the lower extremities. Serious injury could be incurred if the client 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.
What is the priority nursing action to address the client's needs related to her repaired 4th
degree perineal laceration? - Correct Answers-Apply perineal ice packs consistently for the first
24 hours
Rationale: 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.
Early detection and intervention for postpartum complications promotes positive client
outcomes. Postpartum protocol requires that the nurse assess the client'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.
The nurse performs the first assessment upon the client's arrival to the postpartum unit. Where
would the nurse expect to palpate the fundus? - Correct Answers-1 cm above the umbilicus
Rationale: For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus.
Postpartum Crisis Fifteen minutes after the initial assessment, the nurse finds the client
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? - Correct Answers-
Massage the Fundus
Rationale: This is an important action, since the client is hemorrhaging and is probably
hemodynamically unstable. However, this is not the priority.
What is the best method for the nurse to use to obtain immediate assistance? - Correct
Answers-Activate the priority call light from the bedside
Rationale: 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.
The nurse has requested assistance and personnel are on their way. While waiting for help to
arrive, what is the next priority action? - Correct Answers-Assess for bladder distension
Rationale: The client is 2 hours post-delivery with an IV infusion at 125 mL/hour, which can
contribute to diuresis. A distended bladder impedes uterine contraction and contributes to
excessive bleeding. After the fundus is massaged, the bladder should be checked for distention.
The charge nurse, two staff nurses, and an unlicensed assistive personnel (UAP) rush in to assist
the nurse with the client. Which task is best delegated to the UAP during this crisis? - Correct
Answers-Obtain the vital signs and O2 saturation
Rationale: Obtaining vital signs and pulse oximetry are within the scope of practice for the UAP,
and the nurse should interpret these findings as indications of hypovolemia due to blood loss
and should also report the findings to the health care provider.
The HCP is notified that the client 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 order includes stat oxytocin 10 units in each
liter of normal saline to infuse at 40 milliunits (mU)/minute. How many mL of oxytocin should
revision material. You got this champ!
- Correct Answers-The client is gravida 2, para 2 and is transferred to the postpartum unit 1
hour after delivery of a 8 lb, 1 oz infant. She was in labor for 16 hours and forceps were used to
assist with the delivery. The client was given an epidural for anesthesia that was effective. The
labor and delivery nurse reported that the client 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 4 hours ago. Her spouse was at the bedside for delivery and appeared
supportive.
Prior to discontinuing the IV oxytocin, which assessment is most important for the nurse to
obtain? - Correct Answers-Uterine firmness
Rationale: Oxytocine 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.
Assessment: A 1,000 mL bag of Lactated Ringer's solution containing 10 units of oxytocin is
infusing via an 18 guage peripheral IV in the left forearm at 125 mL per hour, with 300 mL
remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued
when this bag's infusion is complete. - Correct Answers-
The postpartum client has minimal sensation in her lower extremities, due to the effects of the
epidural anesthesia. What is the priority nursing concern for this client? - Correct Answers-Fall
Risk
Rationale: Epidural anesthesia causes temporary loss of voluntary movement and muscle
strength in the lower extremities. Serious injury could be incurred if the client 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.
What is the priority nursing action to address the client's needs related to her repaired 4th
degree perineal laceration? - Correct Answers-Apply perineal ice packs consistently for the first
24 hours
Rationale: 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.
Early detection and intervention for postpartum complications promotes positive client
outcomes. Postpartum protocol requires that the nurse assess the client'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.
The nurse performs the first assessment upon the client's arrival to the postpartum unit. Where
would the nurse expect to palpate the fundus? - Correct Answers-1 cm above the umbilicus
Rationale: For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus.
Postpartum Crisis Fifteen minutes after the initial assessment, the nurse finds the client
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? - Correct Answers-
Massage the Fundus
Rationale: This is an important action, since the client is hemorrhaging and is probably
hemodynamically unstable. However, this is not the priority.
What is the best method for the nurse to use to obtain immediate assistance? - Correct
Answers-Activate the priority call light from the bedside
Rationale: 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.
The nurse has requested assistance and personnel are on their way. While waiting for help to
arrive, what is the next priority action? - Correct Answers-Assess for bladder distension
Rationale: The client is 2 hours post-delivery with an IV infusion at 125 mL/hour, which can
contribute to diuresis. A distended bladder impedes uterine contraction and contributes to
excessive bleeding. After the fundus is massaged, the bladder should be checked for distention.
The charge nurse, two staff nurses, and an unlicensed assistive personnel (UAP) rush in to assist
the nurse with the client. Which task is best delegated to the UAP during this crisis? - Correct
Answers-Obtain the vital signs and O2 saturation
Rationale: Obtaining vital signs and pulse oximetry are within the scope of practice for the UAP,
and the nurse should interpret these findings as indications of hypovolemia due to blood loss
and should also report the findings to the health care provider.
The HCP is notified that the client 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 order includes stat oxytocin 10 units in each
liter of normal saline to infuse at 40 milliunits (mU)/minute. How many mL of oxytocin should
