Maternity HESI Case Study |\ |\ |\ |\
Questions with answers |\ |\
The nurse performs the first assessment upon the client's arrival to
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the postpartum unit. Where would the nurse expect to palpate the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
fundus?
a. 3 cm above the umbilicus.
|\ |\ |\ |\ |\
b. 1 cm above the umbilicus.
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c. To the right of the umbilicus.
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d. Midway between the umbilicus and the pubic bone. - CORRECT
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ANSWERS ✔✔b. 1 cm above 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 the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
client disoriented and lying on her back in a pool of vaginal blood,
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with the sheets beneath her saturated with blood.
|\ |\ |\ |\ |\ |\ |\
,Which action is most important for the nurse to implement
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
immediately?
a. Take vital signs
|\ |\ |\
b. Massage the fundus
|\ |\ |\
c. Check the bladder
|\ |\ |\
d. Increase the IV rate - CORRECT ANSWERS ✔✔b. Massage the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
fundus.
Since a boggy fundus is the most likely reason for this client's
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
hemorrhaging, massing 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.
|\ |\ |\ |\ |\ |\ |\ |\
what is the most likely reason a postpartum patient would be
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
hemorrhaging? - CORRECT ANSWERS ✔✔uterine atony (a "boggy" |\ |\ |\ |\ |\ |\ |\
fundus)
|\
,What should be assessed immediately after fundus is massaged and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
nurse has called for help? - 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.
When the nurse conducts a gestational age assessment, which
|\ |\ |\ |\ |\ |\ |\ |\ |\
findings may indicate postmaturity? (Select all that apply. One,
|\ |\ |\ |\ |\ |\ |\ |\ |\
some, or all options may be correct.)
|\ |\ |\ |\ |\ |\
a. Testes descended, good rugae.
|\ |\ |\ |\
b. Formed ears with instant recall.
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c. Peeling, parchment-like skin.
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d. Thin with loose skin and little subcutaneous fat.
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, e. Deep creases at the base of the toes extending to the heels. -
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CORRECT ANSWERS ✔✔c. d. and e. |\ |\ |\ |\ |\ |\
c. Peeling, parchment-like skin.
|\ |\ |\
d. Thin with loose skin and little subcutaneous fat.
|\ |\ |\ |\ |\ |\ |\ |\
--> Subcutaneous fat, which had been used for nourishment, is lost
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
prior to birth. This results in the infant's low temperature.
|\ |\ |\ |\ |\ |\ |\ |\ |\
e. Deep creases at the base of the toes extending to the heels.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
--> Postterm infants develop deep creases on the feet, extending
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
from the base |\ |\
The infant has a reddish papular rash across his face. How should
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the nurse respond when the client asks about the rash?
|\ |\ |\ |\ |\ |\ |\ |\ |\
a. Don't worry about it. This rash will go away in a couple of days.
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Questions with answers |\ |\
The nurse performs the first assessment upon the client's arrival to
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the postpartum unit. Where would the nurse expect to palpate the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
fundus?
a. 3 cm above the umbilicus.
|\ |\ |\ |\ |\
b. 1 cm above the umbilicus.
|\ |\ |\ |\ |\
c. To the right of the umbilicus.
|\ |\ |\ |\ |\ |\
d. Midway between the umbilicus and the pubic bone. - CORRECT
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
ANSWERS ✔✔b. 1 cm above 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 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?
a. Take vital signs
|\ |\ |\
b. Massage the fundus
|\ |\ |\
c. Check the bladder
|\ |\ |\
d. Increase the IV rate - CORRECT ANSWERS ✔✔b. Massage the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
fundus.
Since a boggy fundus is the most likely reason for this client's
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
hemorrhaging, massing 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.
|\ |\ |\ |\ |\ |\ |\ |\
what is the most likely reason a postpartum patient would be
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
hemorrhaging? - CORRECT ANSWERS ✔✔uterine atony (a "boggy" |\ |\ |\ |\ |\ |\ |\
fundus)
|\
,What should be assessed immediately after fundus is massaged and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
nurse has called for help? - 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.
When the nurse conducts a gestational age assessment, which
|\ |\ |\ |\ |\ |\ |\ |\ |\
findings may indicate postmaturity? (Select all that apply. One,
|\ |\ |\ |\ |\ |\ |\ |\ |\
some, or all options may be correct.)
|\ |\ |\ |\ |\ |\
a. Testes descended, good rugae.
|\ |\ |\ |\
b. Formed ears with instant recall.
|\ |\ |\ |\ |\
c. Peeling, parchment-like skin.
|\ |\ |\
d. Thin with loose skin and little subcutaneous fat.
|\ |\ |\ |\ |\ |\ |\ |\
, e. Deep creases at the base of the toes extending to the heels. -
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
CORRECT ANSWERS ✔✔c. d. and e. |\ |\ |\ |\ |\ |\
c. Peeling, parchment-like skin.
|\ |\ |\
d. Thin with loose skin and little subcutaneous fat.
|\ |\ |\ |\ |\ |\ |\ |\
--> Subcutaneous fat, which had been used for nourishment, is lost
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
prior to birth. This results in the infant's low temperature.
|\ |\ |\ |\ |\ |\ |\ |\ |\
e. Deep creases at the base of the toes extending to the heels.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
--> Postterm infants develop deep creases on the feet, extending
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
from the base |\ |\
The infant has a reddish papular rash across his face. How should
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the nurse respond when the client asks about the rash?
|\ |\ |\ |\ |\ |\ |\ |\ |\
a. Don't worry about it. This rash will go away in a couple of days.
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