HESI Case Studies–Obstetrics/Maternity-Postpartum (Marie Wilson)

1. Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the nurse to obtain?
Uterine firmness
2. What is the priority nursing diagnosis for Marie, who is experiencing residual effects of epidural anesthesia?
Risk for injury
3. What is the priority nursing action to address Marie’s needs related to the repair of her 4th degree perineal laceration?
Apply perineal ice packs consistently for the first 24-48 hours.
4. Considering Marie’s history, for which postpartal complication is she most at risk?
Hemorrhage
5. The nurse finds Marie disoriented and lying on her back in a pool of vaginal blood…what is the priority nursing action?
Massage the fundus

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6. What is the best method for the nurse to use to obtain immediate assistance?
Activate the priority call light from the bedside.
7. While waiting for help to arrive, what is the next priority action?
Assess for bladder distention
8. Which task is best delegated to the UAP during this crisis?
Obtain the vital signs and O2 saturation
9. How many mL of oxytocin (Pitocin) should the nurse draw up in the syringe to inject into the 1000mL bag of normal saline?
1
10. What is the flow rate needed to deliver 40 mU/minute?
240
11. Which finding is most indicative that the medication is reaching a therapeutic level?
Firm fundus
12. Considering the client’s history, what etiology is most likely?
Uterine atony
13. What intervention should the nurse implement to communicate the situation to Marie’s husband?
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 children
14. What should the nurse do to prepare for Marie’s blood transfusion? (Select all that apply)
-Start an additional IV using a 16 or 18 gauge angiocath
-Prime a new Y-set blood tubing using a new bag of normal saline.
-Explain the blood transfusion process to Marie
15. Marie’s infant needs to be fed…what is the best thing for Marie’s nurse to do?
Explain Marie’s history and request that the infant be fed with formula in the nursery
16. What should the nurse do in response to these assessment findings?
Provide a warm blanket and continue to monitor
17. What is the difference in Marie’s intake and output?
205
18. The nurse is aware that while Marie’s condition is stabilizing, Marie is still at risk for hemodynamic changes. What action should the nurse take next, based on the assessment data just obtained?
Palpate Marie’s bladder for fullness and catheterize if indicated
19. Considering Marie’s history, what would be the most likely cause of Marie’s headache?
Epidural anesthesia
20. Considering Marie’s history and acuity level, who is the best nurse to assign to Marie’s care?
Labor and delivery nurse with 12 years of experience, who was called in to work for 4 hours until 2300
21. Who is the best person to speak with Marie’s HCP?
Marie’s nurse, who has already given the shift report and is preparing to clock out
22. Which task is best for the nurse to delegate to the UAP?
Obtain and document Marie’s vital signs
23. What further teaching would be the most important for the nurse to include at this time?
Indications and mechanism of action of caffeine sodium benzoate
24. Based on this information, what is the correct nursing action?
Allow Marie to rest during the blood transfusion, and administer the RhoGam as prescribed at a later time.
25. What priority action should the nurse implement?
Notify the security personnel and direct all staff to report to their assigned exit in the hospital
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