HESI RN Case Study: Postpartum

Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the nurse to obtain? - correct 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? - correct 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? - correct 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? - correct 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? - correct 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? - correct 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? - correct 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? - correct 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? - correct answer 0.5 How many mL of Methylegonovine (Methergine) should the nurse draw up in the syringe to administer to Mari? - correct answer 0.25 Which finding is most indicative that the medication is reaching a therapeutic level? - correct 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? - correct 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? - correct 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). - correct 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.