HESI Case Study: Postpartum| NURS 2863 | GRADED A+

HESI Case Study: PostpartumNURS 2863 Prior to discontinuing the IV Pitocin (oxytocin), which assessment is most important for the nurse to obtain? A. Vital signs. B. Vaginal discharge. C. Uterine firmness. D. Oral intake What is the priority nursing diagnosis for a patient who is experiencing residual effects of epidural anesthesia? A. Risk for injury. B. Impaired physical mobility. C. Altered urinary elimination. D. Risk for infection. What is the priority nursing action to address a patient's needs related to the repair of a 4th degree perineal laceration? A. Provide prescribed oral pain medication and stool softener. B. Encourage warm sits baths 2 to 3 times daily C. Apply perineal ice packs consistently for the first 24 to 48 hours. D. Teach proper and frequent use of the peril-bottle. A patient has a history of prolonged labor, multiparous, large baby. Which postpartal complication is she most at risk for? A. Endometritis B. Subinvolution C. Deep vein thrombosis D. Hemorrhage The nurse finds the patient disoriented and lying on her back in a pool of vaginal blood, with the sheets beneath her saturated with blood. What is the priority nursing action? A. Massage the fundus B. Take vital signs. C. Increase the IV rate. D. Check the bladder. What is the best method for the nurse to use to obtain immediate assistance? A. Telephone the health care provider from the client's room. B. Go to the Nurse's station to notify the charge nurse. C. Activate the priority call light from the bedside. D. Call for help from the doorway of the client's room. While waiting for help to arrive, what is the next priority action? A. Obtain vital signs. B. Apply oxygen. C. Assess for bladder distention. D. Increase the IV infusion rate. Which task is best delegated to the UAP during this crisis? A. Bring IV fluids and supplies from the supply room. B. Change the bed linens and bathe the client. C. Start O2 per nasal cannily D. Obtain the vital signs and O2 saturation. The health care provider's prescription includes STAT oxytocin 10u in each liter of NS to infuse at 40mu/minute. A vial of oxytocin is labeled 10 units/mL. How many mL of oxytocin should the nurse draw up in the syringe to inject into the 1000mL bag of normal saline? A. 1mL B. 10mL C. 4mL D. 0.04mL What is the flow rate needed to deliver 40mU/minute? 240mL Drip concentration 10,000mu/1,000mL 40mU/1m x 60m/1hr = 2,400mU/1h 2,400mU/ x mL = 10,000mU/1,000mL 10,000x = 2,400,000/10,000 x = 240 mL/h The oxytocin has been infusing for 20min. The nurse reassesses the client. Which finding is most indicative that the medication is reaching a therapeutic level? A. BP 74/44 B. HR 94 C. O2 Sat 85% D. Firm fundus Considering the patient's recent hemorrhage, what etiology is most likely? A. Perineal laceration B. Retained placental parts C. Uterine agony D. Coagulopathy The patient tells the nurse that her husband went home to pick up their children and bring them to the hospital. The client states that she doesn't want her children to see her this way. What intervention should the nurse implement to communicate the situation to the patient's husband? A. Ask the unit clerk to notify the husband about the patient's change in condition, but let him know that she is going to be all right. B. Call the husband from the nurses' station to inform him of his wife's status and request that he come to the hospital soon w/o the children. C. Dial the telephone number for the patient and hold the phone for her allowing her to talk to her husband and explain what happened. D. Wait until the husband arrives at the hospital w/the children and talk to him before he goes in to see his wife. What should the nurse do to prepare the patient's blood transfusion? (SATA) A. Reduce complications of rapid transfusion by using a blood warmer. B. Start an additional IV using a 16 or 18 gauge angiocath C. Prime a new Y-set blood tubing using a new bag of NS D. Monitor for fluid overload by assess lab results, UOP, respiratory status E. Explain the blood transfusion to the patient. The nurse is getting ready to administer a unit of blood when the nursery brings in the patient's infant to nurse. What is the best thing for the nurse to do? A. Encourage the patient to nurse the infant while proceeding w/the blood administration B. Delay hanging the blood for 15-20m until the patient finishes nursing the infant C. Request that the infant be brought back in an hour to give the blood time to take effect. D. Explain the patient's history and request that the infant be fed with formula in the nursery D. Explain the patient's history and request that the infant be fed with formula in the nursery Ⓒ Fifteen minutes after the transfusion VS are taken: T98.5, BP76/48, HR112, RR22. The patient complains of being cold. What should the nurse do in response to these assessment findings? A. Decrease the rate of the transfusion to 50mL/h B. Stop the transfusion and call the health care provider C. Provide a warm blanket and continue to monitor Intake: 2,435mL. Output: 2,200mL. The nurse is aware that while the patient is stabilizing she is still at risk for further hemodynamic complications. What action should the nurse take next, based on the assessment data just obtained? A. Contact RT to obtain an ABG to verify the SaO2 reading. B. Restrict the patient's PO fluid intake to balance I/O. C. Palpate the patient's bladder for fullness and catheterize if indicated D. Request a prescription for hourly H/H The patient complains that she developed a headache when sitting upright and that the headache leases when lying down. The pain is intensified when she moves her head. Considering the patient's history, what would most likely cause the patient's headache? A. O2 (3LNC) B. Epidural anesthesia C. Straining during delivery D. Side effects of oxytocin Shift change. Considering the patient's history and acuity level, who is the best nurse to assign to the patient? A. An RN who has been licensed for 9months B. L&D RN w/12y experience who is called in to work for 4h until 2300 C. LPN w/15y of postpartum/nursery experience D. Charge nurse w/5y experience who oversees care during the night shift and carries 1/2 of the client assignment load until 1300 As the nurse is preparing to leave for the evening, the patient's health care provider calls. Who is the best person to speak with the HCP? A. The unit clerk who answered the call B. The patient's nurse who has already given the shift report and is preparing to clock out. C. The charge nurse who is leaving, but is sitting at the desk finishing up some last-minute paperwork D. Marie's new nurse who is still receiving report Which task is the best for the nurse to delegate to the UAP? A. Go to the blood bank and pick up the second unit of A- blood. B. Provide peri-care so the nurse can insert the Foley C. Obtain and document the patient's VS D. Check on the status of the patient's infant and assure the patient that the infant is receiving good care The patient's new nurse prepares to administer the caffeine and sodium benzoate. She explains the headaches are d/t PDPH that occurs after epidural. What further teaching would be most important for the nurse to include at this time? A. Indications and MOA of caffeine sodium benzoate B. Reason for the Foley until the headache resolves C. PDPH is usually accompanied by nausea, and Zofran is available PRN D. Strict, reclined bed rest and severe headaches may limit breastfeeding ability The blood bank calls and tells the nurse that the patient's blood type is A+, and the blood drawn from the patient after delivery indicates that she is indirect Coombs' negative and non-sensitized. Based on this info, what is the correct nursing action? A. Obtain RhoGam from the blood bank and administer ASAP B. Allow patient to rest during the transfusion and administer the RhoGam as prescribed at a later time C. Notify the HCP and request a Coombs's positive blood test for mom and baby D. Document the findings in the client record, and pass info to day shift The patient's husband freaks out and takes the infant. What priority action should the nurse implement? A. Notify the security personnel and direct all staff to report to their assigned exit B. Document the observation in the client record C. Notify the HCP D. Request pastoral care personnel