HESI RN ;POSTPARTUM
EXAMINATION 2025/2026 GRADED A+
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.
The nurse has requested assistance and personnel are on their way. While waiting
for help to arrive, what is the next priority action? - ANSWER-C) 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 excesive 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 Mari. Which task is best delegated to the UAP
during the crisis? - ANSWER-D) Obtain the vital signs and O2 saturation.
Both are within the scope of practice for the UAP, and the nurse should interpret
thses findings as indications of hypovolemia due to blood loss and should also be
report the findings to the HCP.
How many mL of oxytocin (Pitocin) should the nurse draw up in the syringe to
inject into the 1000mL bag of normal saline? - ANSWER-0.5
How many mL of Methylegonovine (Methergine) should the nurse draw up in the
syringe to administer to Mari? - ANSWER-0.25
Which finding is most indicative that the medication is reaching a therapeutic
level? - ANSWER-D) Firm fundus.
The desired therapeutic effect of oxytocin (Pitocin) is to cause potent and selective
stimulation of uterine smooth muscle. A firm fundus indicates uterine contraction
during the postpartum period, which is important to prevent further hemorrhage.
, Postpartum hemorrhage is designated as blood los excess of 500 mL within the
first 24 hours of delivery. Considering the client's history, what etiology is most
likely? - ANSWER-C) Uterine atony.
The client's history revealed a prolonged labor (muscle fatigue) and a large baby
(uterine overdistention). These are both frequent causes of uterine atony.
What intervention should the nurse implement to communicate the situation to
Mari's husband? - ANSWER-B) Call Mr. Wilson from the nurses' station to inform
him of his wife's status and request that he come to the hospital soon, without the
other child.
What should the nurse do to prepare for Mari's blood transfusion? (Select all that
apply). - ANSWER-B) Start an additional IV using a 16 to 18 gauge angiocath.
C) Prime a new Y-set tubing using a new bag of normal saline.
E) Obtain a baseline set of vital signs.
What is the best thing for Mari's nurse to do? - ANSWER-D) Explain Mari's
history and request that the infant is fed with formula in the nursery.
Condition is too unstable for her to fed her infant. Even though breastfeeding will
stimulate uterine contractions, this is not as important as client stability.
What should the nurse do in response to these assessment findings? - ANSWER-C)
Provide a warm blanket and continue to monitor.
EXAMINATION 2025/2026 GRADED A+
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.
The nurse has requested assistance and personnel are on their way. While waiting
for help to arrive, what is the next priority action? - ANSWER-C) 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 excesive 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 Mari. Which task is best delegated to the UAP
during the crisis? - ANSWER-D) Obtain the vital signs and O2 saturation.
Both are within the scope of practice for the UAP, and the nurse should interpret
thses findings as indications of hypovolemia due to blood loss and should also be
report the findings to the HCP.
How many mL of oxytocin (Pitocin) should the nurse draw up in the syringe to
inject into the 1000mL bag of normal saline? - ANSWER-0.5
How many mL of Methylegonovine (Methergine) should the nurse draw up in the
syringe to administer to Mari? - ANSWER-0.25
Which finding is most indicative that the medication is reaching a therapeutic
level? - ANSWER-D) Firm fundus.
The desired therapeutic effect of oxytocin (Pitocin) is to cause potent and selective
stimulation of uterine smooth muscle. A firm fundus indicates uterine contraction
during the postpartum period, which is important to prevent further hemorrhage.
, Postpartum hemorrhage is designated as blood los excess of 500 mL within the
first 24 hours of delivery. Considering the client's history, what etiology is most
likely? - ANSWER-C) Uterine atony.
The client's history revealed a prolonged labor (muscle fatigue) and a large baby
(uterine overdistention). These are both frequent causes of uterine atony.
What intervention should the nurse implement to communicate the situation to
Mari's husband? - ANSWER-B) Call Mr. Wilson from the nurses' station to inform
him of his wife's status and request that he come to the hospital soon, without the
other child.
What should the nurse do to prepare for Mari's blood transfusion? (Select all that
apply). - ANSWER-B) Start an additional IV using a 16 to 18 gauge angiocath.
C) Prime a new Y-set tubing using a new bag of normal saline.
E) Obtain a baseline set of vital signs.
What is the best thing for Mari's nurse to do? - ANSWER-D) Explain Mari's
history and request that the infant is fed with formula in the nursery.
Condition is too unstable for her to fed her infant. Even though breastfeeding will
stimulate uterine contractions, this is not as important as client stability.
What should the nurse do in response to these assessment findings? - ANSWER-C)
Provide a warm blanket and continue to monitor.
