HESI RN EXIT CASE STUDY - POSTPARTUM
1. 1. Prior to discontinuing the IV oxytocin, which assessment is most
impor-tant for the nurse to obtain
Answer: Uterine firmness.
2. 2. The postpartum client has minimal sensation in her lower extremities
dueto the effects of the epidural anesthesia. What is the priority nursing
concern for this client
Answer: Fall risk.
3. 3. What is the priority nursing action to address the client's needs
related to her repaired 4th degree perineal laceration
Answer: Apply perineal ice packs consis-tently for the first 24 hours.
4. 4. The nurse performs the first assessment upon the client's arrival to
thepostpartum unit. Where would the nurse expect to palpate the fundus
Answer: 1 cmabove the umbilicus.
5. Fifteen minutes after the initial assessment, the nurse finds the client
disori- ented and lying on her back in a pool of vaginal blood, with the
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, sheets beneathher saturated with blood.
5.Which action is most important for the nurse to implement immediately
Answer: -
Massage the fundus.
6. 6. What is the best method for the nurse to use to obtain immediate
assis-tance
Answer: Activate the priority call light from the bedside.
7. 7. The nurse has requested assistance and personnel are on their way.
Whilewaiting for help to arrive, what is the next priority action
Answer: Assess for bladder distention.
8.8. The charge nurse, two staff nurses, and an unlicensed assistive
personnel(UAP) rush in to assist the nurse with the client. Which task is
best delegatedto the UAP during this crisis
Answer: Obtain the vital signs and O2 saturation.
9. 9. The HCP is notified that the client is hemorrhaging and has an
estimatedblood loss of 1,200 mL since delivery. Her blood pressure is
70/40 mmHg, pulse 120 beats/min, respirations 28 breaths/min, and O2
saturation 73%. TheHCP's prescription includes stat oxytocin 10 units in
each liter of normal salineto infuse at 40 milliunits (mU)/minute. How
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1. 1. Prior to discontinuing the IV oxytocin, which assessment is most
impor-tant for the nurse to obtain
Answer: Uterine firmness.
2. 2. The postpartum client has minimal sensation in her lower extremities
dueto the effects of the epidural anesthesia. What is the priority nursing
concern for this client
Answer: Fall risk.
3. 3. What is the priority nursing action to address the client's needs
related to her repaired 4th degree perineal laceration
Answer: Apply perineal ice packs consis-tently for the first 24 hours.
4. 4. The nurse performs the first assessment upon the client's arrival to
thepostpartum unit. Where would the nurse expect to palpate the fundus
Answer: 1 cmabove the umbilicus.
5. Fifteen minutes after the initial assessment, the nurse finds the client
disori- ented and lying on her back in a pool of vaginal blood, with the
1/4
, sheets beneathher saturated with blood.
5.Which action is most important for the nurse to implement immediately
Answer: -
Massage the fundus.
6. 6. What is the best method for the nurse to use to obtain immediate
assis-tance
Answer: Activate the priority call light from the bedside.
7. 7. The nurse has requested assistance and personnel are on their way.
Whilewaiting for help to arrive, what is the next priority action
Answer: Assess for bladder distention.
8.8. The charge nurse, two staff nurses, and an unlicensed assistive
personnel(UAP) rush in to assist the nurse with the client. Which task is
best delegatedto the UAP during this crisis
Answer: Obtain the vital signs and O2 saturation.
9. 9. The HCP is notified that the client is hemorrhaging and has an
estimatedblood loss of 1,200 mL since delivery. Her blood pressure is
70/40 mmHg, pulse 120 beats/min, respirations 28 breaths/min, and O2
saturation 73%. TheHCP's prescription includes stat oxytocin 10 units in
each liter of normal salineto infuse at 40 milliunits (mU)/minute. How
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