HESI Case Study: Postpartum.Perfect revision
material. Don’t miss out excellence!
a 1,000mL bag of Lactated Ringer's solution containing 10 units of oxytocin (Pitocin) is infusing
via an 18 guage peripheral IV in the left forearm at 125mL per hour, with 300mL remaining in
the bag. the IV is patent, without redness or swelling, and can be discontinued when this bag's
infusion is complete.
1. prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the
nurse to obtain? - Correct Answers-uterine firmness
(oxytocin (Pitocin) 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)
2. 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? - Correct Answers-risk for injury
(epidural anesthesia causes temporary loss of voluntary movement and muscle strength in the
lower extremities. serious injury could be incurred if Marie 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)
3. what is the priority nursing action to address Marie's needs related to the repair of her 4th
degree perineal laceration? - Correct Answers-apply perineal ice packs consistently for the first
24 to 48 hours
(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 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 minutes for the first hour and
then every hour for the next 3 hours.
4. the nurse performs the first assessment upon arrival to the postpartum unit. where would
the nurse expect to palpate the fundus? - Correct Answers-1 cm about the umbilicus
(for the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus)
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.
5. which action is most important for the nurse to implement immediately? - Correct Answers-
massage the fundus
(since a boggy fundus is the most likely reason for this client's hemorrhaging, massaging the
fundus is the most important intervention. the nurse should also call for assistance due to the
amount of blood that has pooled under the client)
6. what is the best method for the nurse to use to obtain immediate assistance? - Correct
Answers-activate the priority call light from the bedside
(the priority call light signals to the entire nursing unit that a client is in a crisis. all personnel
available will respond to the distress signal)
7. 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 distention
(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)
8. 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? - Correct
Answers-obtain the vital signs and O2 saturation
(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)
9. the HCP is notified that Marie is hemorrhaging and has an estimated blood loss of 1,200mL
material. Don’t miss out excellence!
a 1,000mL bag of Lactated Ringer's solution containing 10 units of oxytocin (Pitocin) is infusing
via an 18 guage peripheral IV in the left forearm at 125mL per hour, with 300mL remaining in
the bag. the IV is patent, without redness or swelling, and can be discontinued when this bag's
infusion is complete.
1. prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the
nurse to obtain? - Correct Answers-uterine firmness
(oxytocin (Pitocin) 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)
2. 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? - Correct Answers-risk for injury
(epidural anesthesia causes temporary loss of voluntary movement and muscle strength in the
lower extremities. serious injury could be incurred if Marie 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)
3. what is the priority nursing action to address Marie's needs related to the repair of her 4th
degree perineal laceration? - Correct Answers-apply perineal ice packs consistently for the first
24 to 48 hours
(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 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 minutes for the first hour and
then every hour for the next 3 hours.
4. the nurse performs the first assessment upon arrival to the postpartum unit. where would
the nurse expect to palpate the fundus? - Correct Answers-1 cm about the umbilicus
(for the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus)
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.
5. which action is most important for the nurse to implement immediately? - Correct Answers-
massage the fundus
(since a boggy fundus is the most likely reason for this client's hemorrhaging, massaging the
fundus is the most important intervention. the nurse should also call for assistance due to the
amount of blood that has pooled under the client)
6. what is the best method for the nurse to use to obtain immediate assistance? - Correct
Answers-activate the priority call light from the bedside
(the priority call light signals to the entire nursing unit that a client is in a crisis. all personnel
available will respond to the distress signal)
7. 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 distention
(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)
8. 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? - Correct
Answers-obtain the vital signs and O2 saturation
(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)
9. the HCP is notified that Marie is hemorrhaging and has an estimated blood loss of 1,200mL
