HESI Postpartum Case Study. Excellent
revision guide. Work smart champ!
Marie Wilson, a 34-year-old client who is gravida 4, para 3, is transferred to the postpartum
unit 2 hours after a prolonged 14-hour labor and forceps delivery of a male infant weighing 9 lb,
2 oz. The placenta was intact upon delivery. The labor and delivery nurse reports that Marie
was catheterized for 600 mL of yellow urine just before delivery. Her record indicates that she
had a repair of a 4th degree laceration. A postpartum assessment reveals that her vital signs are
stable; blood pressure 120/80, pulse 84, respirations 20, temperature 98.9° F. Additional
assessment indicates that her fundus is firm and located 1 cm above the umbilicus, and the
perineal sutures are intact with edges well-approximated. The client describes herself as
exhausted and without pain; she has had no sensation below her waist since receiving epidural
anesthesia. - Correct Answers-
Prior to discontinuing the IV Pitocin (oxytocin), which assessment is most important for the
nurse to obtain?
What is the priority nursing diagnosis for a patient who is experiencing residual effects of
epidural anesthesia?
What is the priority nursing action to address a patient's needs related to the repair of a 4th
degree perineal laceration?
Considering she has a history of prolonged labor, multiparous, large baby. Which postpartal
complication is she most at risk for?
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?
What is the best method for the nurse to use to obtain immediate assistance?
While waiting for help to arrive, what is the next priority action?
Which task is best delegated to the UAP during this crisis?
How many mL of oxytocin should the nurse draw up in the syrin - Correct Answers-Uterine
firmness.
revision guide. Work smart champ!
Marie Wilson, a 34-year-old client who is gravida 4, para 3, is transferred to the postpartum
unit 2 hours after a prolonged 14-hour labor and forceps delivery of a male infant weighing 9 lb,
2 oz. The placenta was intact upon delivery. The labor and delivery nurse reports that Marie
was catheterized for 600 mL of yellow urine just before delivery. Her record indicates that she
had a repair of a 4th degree laceration. A postpartum assessment reveals that her vital signs are
stable; blood pressure 120/80, pulse 84, respirations 20, temperature 98.9° F. Additional
assessment indicates that her fundus is firm and located 1 cm above the umbilicus, and the
perineal sutures are intact with edges well-approximated. The client describes herself as
exhausted and without pain; she has had no sensation below her waist since receiving epidural
anesthesia. - Correct Answers-
Prior to discontinuing the IV Pitocin (oxytocin), which assessment is most important for the
nurse to obtain?
What is the priority nursing diagnosis for a patient who is experiencing residual effects of
epidural anesthesia?
What is the priority nursing action to address a patient's needs related to the repair of a 4th
degree perineal laceration?
Considering she has a history of prolonged labor, multiparous, large baby. Which postpartal
complication is she most at risk for?
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?
What is the best method for the nurse to use to obtain immediate assistance?
While waiting for help to arrive, what is the next priority action?
Which task is best delegated to the UAP during this crisis?
How many mL of oxytocin should the nurse draw up in the syrin - Correct Answers-Uterine
firmness.
