HESI RN Case Study: Postpartum(Completely solved)
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the
nurse to obtain? correct answers 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? correct answers 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? correct answers 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? correct answers 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? correct answers 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? correct answers 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? correct answers C) Assess for bladder distention.
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the
nurse to obtain? correct answers 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? correct answers 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? correct answers 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? correct answers 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? correct answers 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? correct answers 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? correct answers C) Assess for bladder distention.
