Postpartum HESI Case Study. Excellent revision
material.Go for the A + champ!
A 1,000 mL bag of Lactated Ringer's solution containing 10 units of oxytocin (Pitocin) is infusing
via an 18 gauge peripheral IV in the left forearm at 125 mL per hour, with 300 mL remaining in
the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag's
infusion is complete. - Correct Answers-
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the
nurse to obtain?
A. Vital signs
B. Vaginal discharge
C. Uterine firmness
D. Oral intake - Correct Answers-C. Uterine firmness
Rationale:
Oxytocin (Pitocin) is a hormone used to stimulate uterine contractions and prevent hemorrhage
from the placental site. Prior to discontinuing the IV, it is most important to ensure that the
uterus is contracting by assessing fundal firmness.
Marie has minimal sensation in her lower extremities, due to the effects of the epidural
anesthesia. What is the priority nursing diagnosis for Marie, who is experiencing residual effects
of epidural anesthesia?
A. Risk for injury
B. Impaired physical mobility
C. Altered urinary elimination
D. Risk for infection - Correct Answers-A. Risk for injury
Rationale:
Epidural anesthesia causes temporary loss of voluntary movement and muscle strength in the
, lower extremities. Serious injury could be incurred if Marie attempts to get out of bed on her
own because her legs will be unable to sustain her weight. The nursing priority is to ensure her
safety by implementing use of two side-rails and instructing her to not get out of bed for the
first time without assistance.
What is the priority nursing action to address Marie's needs related to the repair of her 4th
degree perineal laceration?
A. Provide prescribed oral pain medication and stool softener.
B. Encourage warm sitz 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 peri-bottle. - Correct Answers-C. Apply perineal ice
packs consistently for the first 24 to 48 hours.
Rationale:
Topical perineal ice packs cause local vasoconstriction, resulting in decreased swelling and
tissue congestion, preventing a hematoma, as well as promoting comfort. The 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.
Early detection of, and intervention for, postpartum complications promotes positive client
outcomes. Postpartum protocol requires that the nurse assess Marie's vital signs, fundus,
perineum, vaginal bleeding, pain, leg movement, and IV every 15 minutes for the first hour and
then every hour for the next 3 hours. - Correct Answers-
The nurse performs the first assessment upon arrival to the postpartum unit. Where would the
nurse expect to palpate the fundus?
A. 3 cm above the umbilicus
B. 1 cm to the right of the umbilicus
C. 1 cm to the left of the umbilicus
D. 1 cm above the umbilicus - Correct Answers-D. 1 cm above the umbilicus
material.Go for the A + champ!
A 1,000 mL bag of Lactated Ringer's solution containing 10 units of oxytocin (Pitocin) is infusing
via an 18 gauge peripheral IV in the left forearm at 125 mL per hour, with 300 mL remaining in
the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag's
infusion is complete. - Correct Answers-
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the
nurse to obtain?
A. Vital signs
B. Vaginal discharge
C. Uterine firmness
D. Oral intake - Correct Answers-C. Uterine firmness
Rationale:
Oxytocin (Pitocin) is a hormone used to stimulate uterine contractions and prevent hemorrhage
from the placental site. Prior to discontinuing the IV, it is most important to ensure that the
uterus is contracting by assessing fundal firmness.
Marie has minimal sensation in her lower extremities, due to the effects of the epidural
anesthesia. What is the priority nursing diagnosis for Marie, who is experiencing residual effects
of epidural anesthesia?
A. Risk for injury
B. Impaired physical mobility
C. Altered urinary elimination
D. Risk for infection - Correct Answers-A. Risk for injury
Rationale:
Epidural anesthesia causes temporary loss of voluntary movement and muscle strength in the
, lower extremities. Serious injury could be incurred if Marie attempts to get out of bed on her
own because her legs will be unable to sustain her weight. The nursing priority is to ensure her
safety by implementing use of two side-rails and instructing her to not get out of bed for the
first time without assistance.
What is the priority nursing action to address Marie's needs related to the repair of her 4th
degree perineal laceration?
A. Provide prescribed oral pain medication and stool softener.
B. Encourage warm sitz 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 peri-bottle. - Correct Answers-C. Apply perineal ice
packs consistently for the first 24 to 48 hours.
Rationale:
Topical perineal ice packs cause local vasoconstriction, resulting in decreased swelling and
tissue congestion, preventing a hematoma, as well as promoting comfort. The 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.
Early detection of, and intervention for, postpartum complications promotes positive client
outcomes. Postpartum protocol requires that the nurse assess Marie's vital signs, fundus,
perineum, vaginal bleeding, pain, leg movement, and IV every 15 minutes for the first hour and
then every hour for the next 3 hours. - Correct Answers-
The nurse performs the first assessment upon arrival to the postpartum unit. Where would the
nurse expect to palpate the fundus?
A. 3 cm above the umbilicus
B. 1 cm to the right of the umbilicus
C. 1 cm to the left of the umbilicus
D. 1 cm above the umbilicus - Correct Answers-D. 1 cm above the umbilicus
