HESI RN EXIT EXAM MASTERY
MARI'S CASE STUDY - POSTPARTUM HEMORRHAGE
Scenario: Mari is a 32-year-old G2P1 who delivered a 9 lb. 2 oz baby boy via
vaginal delivery with epidural anesthesia. She experienced a prolonged 18-hour
labor and sustained a 4th-degree perineal laceration. She is now 2 hours
postpartum on the mother-baby unit.
QUESTION 1
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most
important for the nurse to obtain?
A) Maternal blood pressure
B) Fundal height
C) Uterine firmness
D) Urinary output
Correct Answer: C) Uterine firmness
Rationale: Oxytocin (Pitocin) is a hormone used to stimulate uterine contractions
and prevent hemorrhage from the placental site. Before discontinuing this
medication, the nurse must ensure the uterus is firmly contracted. If the uterus is
boggy, discontinuing the oxytocin could lead to immediate postpartum
hemorrhage. Uterine firmness is the most direct indicator that the medication is
still needed.
Distractors:
• A (Blood pressure): Important, but not the most direct indicator of oxytocin
effectiveness
• B (Fundal height): Related to uterine involution but doesn't directly confirm
contraction strength
,• D (Urinary output): Monitors kidney function but doesn't evaluate uterine tone
QUESTION 2
Mari has minimal sensation in her lower extremities due to the effects of
epidural anesthesia. What is the priority nursing diagnosis for Mari?
A) Risk for injury
B) Impaired physical mobility
C) Risk for impaired skin integrity
D) Disturbed sensory perception
Correct Answer: A) Risk for injury
Rationale: Epidural anesthesia causes temporary loss of voluntary movement and
muscle strength in the lower extremities. If Mari attempts to get out of bed
independently, her legs will not be able to sustain her weight, putting her at serious
risk for falls and injury. Safety is always the priority.
Distractors:
• B (Impaired mobility): Accurate but not the priority; injury risk is the bigger
concern
• C (Skin integrity): Possible but not immediate or life-threatening
• D (Sensory perception): The sensation loss is the cause, but "Risk for injury" is the
higher-priority nursing diagnosis
QUESTION 3
What is the priority nursing action to address Mari's needs related to the
repair of her 4th-degree perineal laceration?
A) Administer prescribed oral pain medication
B) Encourage sitz baths twice daily
, C) Apply perineal ice packs consistently for the first 24 to 48 hours
D) Teach perineal care with warm water and peri-bottle
Correct Answer: C) Apply perineal ice packs consistently for the first 24 to 48
hours
Rationale: Ice packs cause local vasoconstriction, resulting in decreased swelling
and tissue congestion. They also help prevent hematoma formation and promote
comfort. The first 24-48 hours is the period when tissue is most vulnerable to
swelling from trauma. Hematoma formation could contribute to hypovolemia and
must be prevented.
Distractors:
• A (Pain medication): Important but not the priority; ice is the first-line intervention
• B (Sitz baths): Should be delayed until after 24-48 hours when swelling subsides
• D (Perineal care): Teaching is important but not the immediate priority
QUESTION 4
The nurse performs the first assessment upon arrival to the postpartum unit.
Where would the nurse expect to palpate Mari's fundus?
A) At the umbilicus
B) 1 cm above the umbilicus
C) 2 cm below the umbilicus
D) 1 cm below the umbilicus
Correct Answer: B) 1 cm above the umbilicus
Rationale: For the first 12 hours postpartum, the fundus should be 1 to 2 cm above
the umbilicus. The fundus gradually descends approximately 1 cm per day and
should be at the umbilicus by day 2, then below the umbilicus by day 3.
, Distractors:
• A (At the umbilicus): Expected on day 2, not immediately postpartum
• C (2 cm below): Expected later in the postpartum period
• D (1 cm below): Expected on day 3-4
QUESTION 5
The nurse assesses Mari's fundus and finds it boggy and deviated to the right,
with a large amount of lochia rubra pooling under her. Which action is most
important for the nurse to implement immediately?
A) Massage the fundus
B) Document the findings
C) Call the healthcare provider
D) Increase the IV oxytocin rate
Correct Answer: A) Massage the fundus
Rationale: A boggy fundus is the most likely reason for postpartum hemorrhage.
Massaging the fundus stimulates uterine contraction and is the immediate priority.
The nurse should also call for assistance due to the amount of blood pooling under
the client. Remember: Massage first, then call for help.
Distractors:
• B (Document): Documentation is important but not the immediate priority
• C (Call HCP): Should be done after massaging and getting assistance
• D (Increase oxytocin): Requires provider order; massage is the immediate nursing
action
QUESTION 6
MARI'S CASE STUDY - POSTPARTUM HEMORRHAGE
Scenario: Mari is a 32-year-old G2P1 who delivered a 9 lb. 2 oz baby boy via
vaginal delivery with epidural anesthesia. She experienced a prolonged 18-hour
labor and sustained a 4th-degree perineal laceration. She is now 2 hours
postpartum on the mother-baby unit.
QUESTION 1
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most
important for the nurse to obtain?
A) Maternal blood pressure
B) Fundal height
C) Uterine firmness
D) Urinary output
Correct Answer: C) Uterine firmness
Rationale: Oxytocin (Pitocin) is a hormone used to stimulate uterine contractions
and prevent hemorrhage from the placental site. Before discontinuing this
medication, the nurse must ensure the uterus is firmly contracted. If the uterus is
boggy, discontinuing the oxytocin could lead to immediate postpartum
hemorrhage. Uterine firmness is the most direct indicator that the medication is
still needed.
Distractors:
• A (Blood pressure): Important, but not the most direct indicator of oxytocin
effectiveness
• B (Fundal height): Related to uterine involution but doesn't directly confirm
contraction strength
,• D (Urinary output): Monitors kidney function but doesn't evaluate uterine tone
QUESTION 2
Mari has minimal sensation in her lower extremities due to the effects of
epidural anesthesia. What is the priority nursing diagnosis for Mari?
A) Risk for injury
B) Impaired physical mobility
C) Risk for impaired skin integrity
D) Disturbed sensory perception
Correct Answer: A) Risk for injury
Rationale: Epidural anesthesia causes temporary loss of voluntary movement and
muscle strength in the lower extremities. If Mari attempts to get out of bed
independently, her legs will not be able to sustain her weight, putting her at serious
risk for falls and injury. Safety is always the priority.
Distractors:
• B (Impaired mobility): Accurate but not the priority; injury risk is the bigger
concern
• C (Skin integrity): Possible but not immediate or life-threatening
• D (Sensory perception): The sensation loss is the cause, but "Risk for injury" is the
higher-priority nursing diagnosis
QUESTION 3
What is the priority nursing action to address Mari's needs related to the
repair of her 4th-degree perineal laceration?
A) Administer prescribed oral pain medication
B) Encourage sitz baths twice daily
, C) Apply perineal ice packs consistently for the first 24 to 48 hours
D) Teach perineal care with warm water and peri-bottle
Correct Answer: C) Apply perineal ice packs consistently for the first 24 to 48
hours
Rationale: Ice packs cause local vasoconstriction, resulting in decreased swelling
and tissue congestion. They also help prevent hematoma formation and promote
comfort. The first 24-48 hours is the period when tissue is most vulnerable to
swelling from trauma. Hematoma formation could contribute to hypovolemia and
must be prevented.
Distractors:
• A (Pain medication): Important but not the priority; ice is the first-line intervention
• B (Sitz baths): Should be delayed until after 24-48 hours when swelling subsides
• D (Perineal care): Teaching is important but not the immediate priority
QUESTION 4
The nurse performs the first assessment upon arrival to the postpartum unit.
Where would the nurse expect to palpate Mari's fundus?
A) At the umbilicus
B) 1 cm above the umbilicus
C) 2 cm below the umbilicus
D) 1 cm below the umbilicus
Correct Answer: B) 1 cm above the umbilicus
Rationale: For the first 12 hours postpartum, the fundus should be 1 to 2 cm above
the umbilicus. The fundus gradually descends approximately 1 cm per day and
should be at the umbilicus by day 2, then below the umbilicus by day 3.
, Distractors:
• A (At the umbilicus): Expected on day 2, not immediately postpartum
• C (2 cm below): Expected later in the postpartum period
• D (1 cm below): Expected on day 3-4
QUESTION 5
The nurse assesses Mari's fundus and finds it boggy and deviated to the right,
with a large amount of lochia rubra pooling under her. Which action is most
important for the nurse to implement immediately?
A) Massage the fundus
B) Document the findings
C) Call the healthcare provider
D) Increase the IV oxytocin rate
Correct Answer: A) Massage the fundus
Rationale: A boggy fundus is the most likely reason for postpartum hemorrhage.
Massaging the fundus stimulates uterine contraction and is the immediate priority.
The nurse should also call for assistance due to the amount of blood pooling under
the client. Remember: Massage first, then call for help.
Distractors:
• B (Document): Documentation is important but not the immediate priority
• C (Call HCP): Should be done after massaging and getting assistance
• D (Increase oxytocin): Requires provider order; massage is the immediate nursing
action
QUESTION 6
