1.
Prior to discontinuing the IV Pitocin (oxytocin), which assessment is most important for the nurse to obtain? A) Vital signs.
Feedback: INCORRECT
Vital sign assessment is important prior to discontinuing the Lactated Ringer’s since the primary IV contributes to the maintenance of cardiovascular stability.
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B) Vaginal discharge.
Feedback: INCORRECT
Expulsion of minimal bright red vaginal discharge is normal after delivery. It is difficult for the nurse to ascertain client stability merely by assessing the vaginal discharge and estimating amounts of vaginal blood loss.
C) Uterine firmness.
Feedback: CORRECT
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.
D) Oral intake.
Feedback: INCORRECT
Assessment of oral fluid intake is important when determining if additional IV fluids are indicated, but it is not the first priority.
Points Earned:
1.0/1.0
Correct Answer(s):
C
2.
What is the priority nursing diagnosis for Marie, who is experiencing residual effects of epidural anesthesia? A) Risk for infection.
Feedback: INCORRECT
The lack of sensation below the waist caused by the residual effects of epidural anesthesia does not pose any real threat of infection, because epidural side effects are unrelated to the mechanisms of infection transmission or development.
B) Risk for injury.
Feedback: CORRECT
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 all four side-rails and instructing her to not get out of bed for the first time without assistance.
C) Impaired physical mobility.
Feedback: INCORRECT
Marie’s impaired physical mobility is temporary and is not likely to cause complications resulting in long-term immobility.
D) Altered urinary elimination.
Feedback: INCORRECT
While the epidural anesthesia may temporarily inhibit Marie’s ability to void voluntarily, this is usually resolved within six hours. Marie should be monitored for bladder fullness during the period that she is unable to sense the need to void, but this concern is secondary to client safety.
Points Earned:
1.0/1.0
Correct Answer(s):
B
3.
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. Feedback: INCORRECT
Marie has no sensation below her waist because of the residual effects of the epidural anesthesia. She does not need pain medication at this time. A stool softener is usually administered within 24 hours of delivery, but it is not a priority at this time.
B) Teach proper and frequent use of the peri-bottle.
Feedback: INCORRECT
It is important for the nurse to instruct Marie in measures to prevent infection, such as frequent and proper perineal hygiene techniques during the postpartum period. However, this teaching is not a priority at this time. Marie is exhausted (therefore not receptive to teaching), and she is unable to get up to the bathroom to void (epidural anesthesia). The more appropriate time to teach use of a peri-bottle is while assisting Marie after she is able to get up and void in the bathroom.
C) Apply perineal ice packs consistently for the first 24 to 48 hours. Feedback: CORRECT
Topical perineal ice packs cause local vasoconstriction, resulting in decreased swelling and tissue congestion, 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.
D) Encourage warm sitz baths 2 to 3 times daily.
Feedback: INCORRECT
Soothing, warm sitz baths should be encouraged, because they increase circulation to the site and promote healing. However, sitz baths are not encouraged until the 2nd or 3rd postpartum day, after the swelling has decreased. Promotion of increased circulation prior to this time will result in increased amounts of swelling, tissue congestion, and pain.
Points Earned:
1.0/1.0
Correct Answer(s):
C
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 three hours.
4.
Considering Marie’s history, which postpartal complication is she most at risk for? A) Deep vein thrombosis.
Feedback: INCORRECT
Venous thrombosis forms in response to inflammation in the vein wall as a result of venous stasis. Factors contributing to the development of deep vein thrombosis in the postpartum client include increased amounts of certain blood clotting factors, obesity, increased maternal age, high parity, prolonged inactivity, anemia, heart disease, and varicosities. Marie’s history does not indicate any risk factors for deep vein thrombosis.
B) Subinvolution.
Feedback: INCORRECT
Subinvolution occurs when the uterus fails to follow the normal pattern of involution, but instead remains enlarged. It is caused by placental fragments or infection. The labor and delivery nurse stated that Marie delivered the entire placenta, i.e., no fragments were retained in the uterus. Marie’s history does not indicate any risk factors for subinvolution.
C) Endometritis.
Feedback: INCORRECT
Endometritis is a uterine infection, one of four types of puerperal (of or pertaining to childbirth) infections. Marie’s history does not include any of the factors that contribute to increased risk for puerperal infection
which are: poor nutritional status, anemia, vaginal infection with group B streptococcus, and diabetes.
D) Hemorrhage.
Feedback: CORRECT
Postpartal hemorrhage indicates loss of greater than 500 ml of blood after the end of the third stage of labor. Causes of early postpartal hemorrhage include uterine atony (relaxation of the uterus), laceration of the genital tract, and retained placental fragments. Factors in Maria’s history that contribute to the potential for hemorrhage include: overdistention of the uterus due to a large infant, the trauma of a forceps delivery, a prolonged labor, and the use of oxytocin.
Points Earned:
1.0/1.0
Correct Answer(s):
D
Postpartum Crisis
Fifteen minutes after the initial assessment, the nurse finds Marie disoriented and lying on her back in a pool of vaginal blood, with the sheets beneath her saturated with blood.
5.
What is the priority nursing action?
A) Take vital signs.
Feedback: INCORRECT
If the nurse takes the vital signs first, time will be lost while the client continues hemorrhaging.
B) Check the bladder.
Feedback: INCORRECT
Several interventions should be implemented simultaneously. Bladder
distention is a common problem that can impede uterine contraction and predispose the client to bleeding, but another action should be implemented immediately.
C) Massage the fundus.
Feedback: CORRECT
Since a boggy fundus is the most likely reason for this client’s hemorrhaging, massaging the fundus is the most important intervention. The nurse should also call for assistance due to the amount of blood that has pooled under the client.
D) Increase the IV rate.
Feedback: INCORRECT
This is an important action since the client is hemorrhaging and is probably hemodynamically unstable.
Points Earned:
1.0/1.0
Correct Answer(s):
C
6.
What is the best method for the nurse to use to obtain immediate assistance? A) Call for help from the doorway of the client’s room.
Feedback: INCORRECT
Although staying with the client is important during a crisis, it is not appropriate to shout in the hallway. This could alarm other clients, and it is not the best way to summon help.
B) Go to the nurse’s station to notify the charge nurse.
Feedback: INCORRECT
The nurse should never leave a critical client’s bedside for any reason. The first rule during a crisis is to stay with the client.
C) Activate the priority call light from the bedside.
Feedback: CORRECT
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.
D) Telephone the healthcare provider from the client’s room. Feedback: INCORRECT
The healthcare provider needs to be notified as soon as possible, but not without collecting data first. The healthcare provider will have questions regarding the client’s status. Anticipating and collecting the necessary data will facilitate effective communication with the healthcare provider.
Points Earned:
1.0/1.0
Correct Answer(s):
C
The nurse has requested assistance and personnel are on their way.
7.
While waiting for help to arrive, what is the next priority action? A) Apply oxygen.
Feedback: INCORRECT
Applying oxygen is important to improve the client’s oxygenation, but it is of less priority than addressing the cause of the hemorrhage.
B) Increase the IV infusion rate.
Feedback: INCORRECT
Greater fluid volume administered intravenously is an important lifesaving action, but this is of less priority than addressing the cause of the hemorrhage.
C) Obtain vital signs.
Feedback: INCORRECT
It is important to assess vital signs, but this is of less priority than addressing the cause of the hemorrhage.
D) Assess for bladder distention.
Feedback: CORRECT
The client is two hours post delivery with an IV infusing at 125 ml/hour, which can contribute to diuresis. A distended bladder impedes uterine contraction and contributes to excessive bleeding. After the fundus is massaged, the bladder should be checked for distention.
Points Earned:
1.0/1.0
Correct Answer(s):
D
The charge nurse, two staff nurses, and an unlicensed assistive personnel (UAP) rush in to assist the nurse with Marie.
8.
Which task is best delegated to the UAP during this crisis?
A) Obtain the vital signs and O2 saturation.
Feedback: CORRECT
Obtaining vital signs and pulse oximetry are within the scope of practice for the UAP, and the nurse should interpret these findings as indications of hypovolemia due to blood loss, and should also report the findings to the healthcare provider.
B) Change the bed linens and bathe the client.
Feedback: INCORRECT
The client is lying in a pool of blood. So at some point, the linens will need to be gathered and weighed to estimate blood loss, and the client will need to be bathed. This should be done when the client is more hemodynamically stable. It is not the priority at this time.
C) Start O2 per nasal cannula.
Feedback: INCORRECT
The UAP can collect the equipment but the nurse should initiate O2 administration.
D) Bring IV fluids and supplies from the supply room.
Feedback: INCORRECT
It will be difficult for a UAP to know exactly which type of IV fluid to obtain. Since there are many sizes and types of fluid to select from in the supply room, there is a greater chance for delay and error if the UAP is sent.
Points Earned:
0.0/1.0
Correct Answer(s):
A
The healthcare provider is notified that Marie is hemorrhaging and has an estimated blood loss of 1,200 ml since delivery. The client’s blood pressure is 70/40, pulse 120, respirations 28, and O2 saturation 73%. The healthcare provider’s prescriptions include stat oxytocin 10 units in each liter of normal saline to infuse at 40 milliunits (mU)/minute. The healthcare provider also prescribes 0.2 mg methylergonovine maleate (Methergine) IM to be given immediately. The vial of oxytocin is labeled 10 units/ml.
9.
How many ml of oxytocin should the nurse draw up in the syringe to inject into the 1000 ml bag of normal saline? A) 0.04 ml.
Feedback: INCORRECT
This answer is incorrect. Please try again.
B) 4 ml.
Feedback: INCORRECT
This answer is incorrect. Please try again.
C) 10 ml.
Feedback: INCORRECT
This answer is incorrect. Please try again.
D) 1 ml.
Feedback: CORRECT
The healthcare provider prescribed 10 units in 1,000 ml of NS. The vial contains 10 units/ml. The nurse should inject 1 ml into the bag of NS.
Points Earned:
1.0/1.0
Correct Answer(s):
D
The oxytocin must be administered via an IV infusion pump.
10.
What is the flow rate needed to deliver 40 mU/minute?
A) 24 ml/hr.
Feedback: INCORRECT
This answer is incorrect. Please try again.
B) 40 ml/hr.
Feedback: INCORRECT
This answer is incorrect. Please try again.
C) 4 ml/hr.
Feedback: INCORRECT
This answer is incorrect. Please try again.
D) 240 ml/hr.
Feedback: CORRECT
Drip concentration = 10,000 mU/1,000 mL.
40 mU/1 min × 60 min/1 hr = 240 mU/1 hr.
240 mU/x ml = 10,000 mU/1,000 ml
10,000 x = 2,400,000/10,000
x = 240 ml/hr.
Points Earned:
1.0/1.0
Correct Answer(s):
D
Initial Stabilization
The oxytocin has been infusing at the prescribed rate for twenty minutes. The nurse reassesses the client.
11.
Which finding is most indicative that the medication is reaching a therapeutic level? A) O2 saturation 85%.
Feedback: INCORRECT
This improvement in O2 saturation primarily indicates that the administration of supplemental oxygen is effective, not the oxytocin.
B) Blood pressure 74/44.
Feedback: INCORRECT
An increase or improvement in the blood pressure indicates that the fluids being administered are treating the hypovolemia, but it does not necessarily mean that the oxytocin is effective.
C) Firm fundus.
Feedback: CORRECT
The desired therapeutic effect of oxytocin 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.
D) Heart rate 94.
Feedback: INCORRECT
A decrease in the heart rate indicates that the fluids being administered are helping maintain fluid volume, but this is not the best indicator of the medication’s effectiveness.
Points Earned:
1.0/1.0
Correct Answer(s):
C
Postpartum hemorrhage is designated as blood loss in excess of 500 ml within the first 24 hours of delivery.
12.
Considering the client’s history, what etiology is most likely? A) Uterine atony.
Feedback: CORRECT
The client’s history revealed a prolonged labor (muscle fatigue) and a large baby (uterine overdistention). These are both frequent causes of uterine atony.
B) Retained placental parts.
Feedback: INCORRECT
The initial report received from the labor and delivery nurse was that the full placenta was delivered.
C) Perineal laceration.
Feedback: INCORRECT
The laceration edges were well approximated and intact.
D) Coagulopathy.
Feedback: INCORRECT
Acquired coagulopathy may be secondary to preeclampsia, sepsis, or significant hemorrhage during delivery. The client’s history did not include these problems.
Points Earned:
1.0/1.0
Correct Answer(s):
A
Marie is pale, weak, and anxious, but no longer disoriented. Her fundus is firm and is 1 cm above the umbilicus. She is receiving O2 per nasal cannula at 4 liters/minute and has an O2 saturation of 88%. Her vital signs are: BP 74/44, pulse 116 and respirations 26. Her bleeding has slowed considerably. The nurse asks the UAP to bathe Marie and change the bed linens. Marie tells the nurse that her husband went home to pick up their three children and bring them to the hospital. She states that she doesn’t want her children to see her this way and asks the nurse to tell Mr. Wilson what has happened.
13.
What intervention should the nurse implement to communicate the situation to Marie’s husband? A) Dial the telephone number for Marie and hold the phone for her, allowing her to talk to her husband and explain what happened. Feedback: INCORRECT
Since Marie is still weak and unable to communicate effectively, it is not appropriate to have her try to explain the situation to her husband on the telephone. In addition, the client expressed a desire for someone else to contact her husband.
B) Wait until Mr. Wilson arrives at the hospital with the children, and talk
to him before he goes in to see his wife. Feedback: INCORRECT
It is best if contact with Mr. Wilson is attempted prior to his arrival at the hospital with the children.
C) Ask the unit clerk to notify Mr. Wilson about Marie’s change in condition, but let him know that she is going to be all right. Feedback: INCORRECT
The unit clerk should not disclose sensitive information to family members by telephone.
D) 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. Feedback: CORRECT
In a crisis situation, the nurse who is caring for Marie should inform Mr. Wilson about his wife’s status, and ask him to return to the unit as soon as possible, preferably without the children.
Points Earned:
1.0/1.0
Correct Answer(s):
D
Blood Transfusion
The healthcare provider prescribes two units of packed red blood cells (PRBCs) to be transfused as soon as possible. Marie signs the consent form, and a blood sample for the type and crossmatch is obtained.
14.
What is the correct way for Marie’s nurse to prepare for the blood transfusion? A) Reduce complications of rapid transfusion by using a blood warmer. Feedback: INCORRECT
Blood warmers do not alleviate complications of rapid volume loading with transfusion.
B) Prime the Y-set blood tubing using the normal saline that is already infusing. Feedback: INCORRECT
The blood administration tubing should be primed with normal saline. However, the NS that is currently infusing has Pitocin added. The Pitocin will react with the blood and cause clotting and hemolysis of the blood cells. In order to use the present IV site, the Pitocin should be discontinued, which is not indicated at this time.
C) Start an additional IV using a 16 or 18 gauge angiocath.
Feedback: CORRECT
Marie needs the current IV site for the continuous infusion of Pitocin. A new IV site will be needed for the blood administration.
D) Monitor for fluid overload by assessing lab results, urine output, and respiratory status. Feedback: INCORRECT
Two units of blood will provide Marie with approximately 450 ml of additional fluid. This will not place Marie at risk for fluid overload, considering her dehydrated state and low blood pressure.
Points Earned:
1.0/1.0
Correct Answer(s):
C
Marie’s nurse is getting ready to administer the first unit of blood when the nursery nurse brings in Marie’s infant son and states that Marie needs to feed him because it has been four hours since the infant last nursed. The infant is sleeping soundly in the crib.
15.
What is the best thing for Marie’s nurse to do?
A) Explain Marie’s history and request that the infant be fed with formula in the nursery. Feedback: CORRECT
Marie’s condition is too unstable to feed her infant. Even though
breastfeeding will stimulate uterine contractions, it is not as important as client stability. The nursery nurse should feed the infant in the nursery until Marie is stable enough to resume breastfeeding.
B) Encourage Marie to nurse the infant while proceeding with the blood administration. Feedback: INCORRECT
Marie is too weak, dehydrated, and unstable to nurse her infant.
C) Request that the infant be brought back in an hour to give the blood time to take effect. Feedback: INCORRECT
Even an hour after receiving blood, Marie will still be too weak, dehydrated, and unstable to nurse her infant.
D) Delay hanging the blood for 15 to 20 minutes until Marie finishes nursing the infant. Feedback: INCORRECT
The healthcare provider prescribed the transfusion as soon as possible. There should be no delays.
Points Earned:
1.0/1.0
Correct Answer(s):
A
Prior to the blood transfusion, the nurse records Marie’s vital signs to be: temperature 97.8° F, blood pressure 78/50, pulse 110, and respirations 22. The blood requisition form, patient identification bracelet, and blood label are checked with another RN, and then the A negative blood transfusion is started at 75 ml/hr. Fifteen minutes after the transfusion is begun, another set of vital signs is taken: temperature 98.5° F, blood pressure 76/48, pulse 112, and respirations 22. Marie complains of being cold.
16.
What should the nurse do in response to these assessment findings? A) Decrease the rate of the transfusion to 50 ml/hr.
Feedback: INCORRECT
The rate of infusion is already running slowly at 75 ml/hr. Decreasing the rate and staying with the client is not going to change anything about the situation.
B) Compare the blood type on the blood labels with the requisition forms. Feedback: INCORRECT
Comparison of the patient’s blood type with the blood labels was done prior to the transfusion. A second comparison will not be helpful after the blood has already been started.
C) Provide a warm blanket and continue to monitor.
Feedback: CORRECT
The administration of cold blood commonly causes the client to feel cold, but does not constitute chills and fever, which are indicative of a febrile nonhemolytic reaction.
D) Stop the transfusion and call the healthcare provider.
Feedback: INCORRECT
Marie is afebrile, and the complaint of feeling cold is not likely to be related to a transfusion reaction.
Points Earned:
1.0/1.0
Correct Answer(s):
C
When the first unit of packed red blood cells (PRBCs) is infused, the nurse performs a targeted assessment. Marie’s fundus remains firm and lochial flow has decreased to a small amount. Her vital signs are – temperature 98.3° F, blood pressure 96/58, pulse 92, and respirations 22. Her oxygen saturation (SaO2) is 92% with 3 liters of oxygen per nasal cannula. The nurse, in preparation for shift change, calculates the intake and output for the past 4 hours as follows: INTAKE:
Oral – 135 ml
IV – 2,000 ml
Blood – 300 ml
Total Intake – 2,435 ml OUTPUT:
Urine – 600 ml (catheterized just prior to birth, ~ 4 hours ago) Bleeding – 1,600 ml
Total Output – 2,200 ml
17.
The nurse is aware that while Marie’s condition is stabilizing, she is still at risk for further hemodynamic complications. What action should the nurse take next, based on the assessment data just obtained? A) Palpate Marie’s bladder for fullness and catheterize if indicated. Feedback: CORRECT
Marie’s bladder has not been emptied since delivery (approximately four hours earlier). It is important to evaluate her urinary output for two reasons. Marie’s kidneys have been stressed by the hemorrhage, and urinary output is one parameter used to measure kidney function, along with blood urea nitrogen (BUN), and serum creatinine levels. In addition, if Marie’s bladder is full it will displace the uterus, inhibiting contraction and increasing the risk of further hemorrhage.
B) Request a prescription for hourly hemoglobin and hematocrit measurements. Feedback: INCORRECT
While hemoglobin and hematocrit measurement will be used to evaluate the efficacy of the blood transfusions, Marie does not need for these tests to be obtained on an hourly schedule since she is not actively bleeding and her vital signs have stabilized. Marie tells the nurse that she has sensation in her lower extremities, can move both her legs, and that she needs to use the
bathroom. The nurse offers Marie the use of a bedpan or bedside commode. Marie replies that she feels slightly dizzy and would like to sit up on the bedpan rather than attempt to get out of bed right now. Marie is able to void 450 ml on the bedpan and reports that she feels she has emptied her bladder completely.
C) Contact respiratory therapy to obtain a blood gas to verify the (SaO2) reading. Feedback: INCORRECT
This would be an action the nurse might initiate if the oxygen saturation is decreasing or is at a crucial level. It is not necessary at this point.
D) Restrict Marie’s oral fluid intake to balance intake and output. Feedback: INCORRECT
There is only a 435 ml difference in intake over output and Marie is showing no signs of fluid overload, so restricting oral intake is not indicated.
Points Earned:
1.0/1.0
Correct Answer(s):
A
Another Postpartum Complication
Marie complains that she developed a headache after she sat upright on the bedpan. She tells the nurse that the headache has lessened to a dull ache after lying back down. The pain is intensified when she moves her head.
18.
Considering Marie’s history, what would be the most likely cause of Marie’s headache? A) Oxygen administration (3 liters/nasal cannula).
Feedback: INCORRECT
Oxygen therapy does not cause headaches.
B) Straining during delivery.
Feedback: INCORRECT
Increased intracranial pressure at the time of straining (pushing during delivery) will sometimes cause a headache at the time the straining occurs, but not six hours later.
C) Epidural anesthesia.
Feedback: CORRECT
Postdural puncture headache (PDPH) sometimes occurs after epidural anesthesia. Its exact pathophysiology is uncertain, but it apparently stems from cerebrospinal fluid (CSF) leakage at the puncture site, which causes a decrease in both CSF volume and intracranial pressure.
D) Side effect of oxytocin.
Feedback: INCORRECT
Oxytocin does not cause headaches. Oxytocin does, at times, cause hypertension, which could contribute to a headache, but Marie’s vital signs reveal that she does not have hypertension at this time.
Points Earned:
1.0/1.0
Correct Answer(s):
C
Delegation and Supervision
The nurse asks the unit clerk to page Marie’s healthcare provider. While Marie’s nurse is at the desk documenting Marie’s shift summary and waiting for the healthcare provider to return the page, the charge nurse asks for assistance in making client care assignments for the next shift.
19.
Considering Marie’s history and acuity level, who is the best nurse to assign to Marie’s care? A) Labor and delivery nurse with 12 years of experience, who was called in to work for 4 hours until 2300. Feedback: CORRECT
This nurse is experienced handling the acute needs of obstetrical clients and would be a great resource for the next four hours in helping stabilize Marie’s condition. Marie, when more stabilized, could then be reassigned at 2300.
B) Charge nurse with 5 years of experience who oversees care during the night shift and carries 1/2 of the client assignment load until 2300. Feedback: INCORRECT
The charge nurse during the next four hours will be tied up with managing the unit, making new admission assignments, handling problems, and overseeing client care. If assigned to care for an unstable client with acute care needs, there is a risk that either the client’s care or the unit management would be neglected.
C) Licensed practical nurse (LPN) with 15 years of postpartum/nursery experience. Feedback: INCORRECT
The licensed practical nurse, even with many years of experience, should not be assigned to care for an unstable client with acute care needs, including the transfusion of a second unit of blood.
D) Registered nurse (RN) who has been licensed for 9 months. Feedback: INCORRECT
This nurse is too inexperienced to be assigned to Marie’s care. The nurse should be assigned to care for more stable postpartum clients.
Points Earned:
1.0/1.0
Correct Answer(s):
A
Marie’s nurse gives the shift report and turns Marie’s care over to the nurse who has been assigned to her care. As she is preparing to leave for the evening, Marie’s healthcare provider calls, returning the page.
20.
Who is the best person to speak with Marie’s healthcare provider? A) The unit clerk who answered the call.
Feedback: INCORRECT
The unit clerk has not been providing care for Marie, nor can a clerk receive telephone prescriptions from the healthcare provider.
B) Marie’s new nurse who is still receiving the in shift report. Feedback: INCORRECT
This nurse is aware of Marie’s needs and concerns, but is still receiving the in shift report, and has not yet had a chance to assess Marie. This nurse would only be able to provide second-hand, limited information to the healthcare provider. This would limit the healthcare provider’s ability to make informed decisions and direct Marie’s care.
C) The charge nurse who is leaving, but is sitting at the desk finishing up some last-minute paperwork. Feedback: INCORRECT
The charge nurse has not been providing direct care to Marie. The charge nurse would be unable to answer the healthcare provider’s specific questions or provide detailed information regarding Marie.
D) Marie’s nurse who has already given the shift report and is preparing to clock out. Feedback: CORRECT
The off-going nurse, who knows the most about Marie and has first-hand information about her symptoms, should be the one to communicate with the healthcare provider. It should only delay the nurse a few minutes to speak with the healthcare provider and record any additional care that is prescribed.
Points Earned:
1.0/1.0
Correct Answer(s):
D
The nurse notifies the healthcare provider of Marie’s status, including receiving the first unit of blood, current vital signs, up to the bathroom to void 450 ml, and about Marie’s severe headache. The healthcare provider confirms that since the migraine is postural in nature, Marie has a postdural puncture headache. The healthcare provider requests continuation of IV fluids as previously prescribed for adequate hydration and then prescribes strict reclined bed rest, Foley catheter, caffeine and sodium benzoate 0.5 g q6h IV, Tylenol #3 with Codeine 1 to 2 tablets PO q4-6 h as needed for pain, and ondansetron (Zofran) 4 mg PO q8h as needed for nausea. Marie’s nurse records the new prescriptions and reports them to the nurse assuming Marie’s care. The UAP approaches Marie’s new nurse and asks if there is anything that the UAP can do to assist in Marie’s care.
21.
Which task is best for the nurse to delegate to the UAP?
A) Provide peri-care so the nurse can insert the Foley catheter. Feedback: INCORRECT
Marie was up to the bathroom, emptied her bladder, and performed peri-care approximately 30 minutes prior. The Foley catheter and the peri-care are not priorities at this time, since her bladder does not immediately need to be emptied. The Foley catheter insertion can be postponed.
B) Go to the blood bank and pick up the second unit of A negative blood. Feedback: INCORRECT
Transfusion of the second unit of blood is the most urgent aspect of Marie’s care at this time. However, some hospitals require a licensed person to sign out blood due to legal liability with incorrectly cross-matched blood.
C) Obtain and document Marie’s vital signs.
Feedback: CORRECT
The UAP should continue to obtain and document Marie’s vital signs, so the nurse has the data necessary to monitor for a delayed transfusion reaction. The nurse is responsible for on-going assessment of the client and preparation for administration of the second transfusion of A negative
blood, which is the highest priority action.
D) Check on the status of Marie’s infant and assure Marie that he is receiving good care. Feedback: INCORRECT
Assurance of her infant’s well-being is important, but not as important as the need for the blood transfusion and relief of her headache. Marie has not recently asked about the infant, indicating that she is not overly anxious or in need of reassurance. This is of less priority than the initiation of the transfusion and relief of Marie’s headache.
Points Earned:
1.0/1.0
Correct Answer(s):
C
Stabilization and Postpartum Care
Marie’s new nurse prepares to administer the caffeine and sodium benzoate 0.5 g IV. She introduces herself to Marie and explains the reason that she is experiencing severe migraines when she gets out of bed is because she has a postdural puncture headache (PDPH) that sometimes occurs after epidural anesthesia. The decrease in intracranial pressure causes severe shifting of fluid, which causes the headache. The nurse explains that the headache and associated symptoms usually last three to five days. They will spontaneously resolve, but until they do, Marie will be given pain medication and placed on strict, reclined bed rest to limit her movement.
22.
What further teaching would be most important for the nurse to include at this time? A) PDPH is usually accompanied by nausea, and Zofran is available as needed. Feedback: INCORRECT
It is not necessary for the nurse to discuss another symptom of PDPH with Marie at this time. She should assess for it, and administer the drug as necessary.
B) Reason for the Foley catheter until the headache resolves. Feedback: INCORRECT
It is important for the nurse to explain this procedure to Marie, but it is not necessary until the nurse plans to insert the catheter. This is not the most important item.
C) Strict, reclined bed rest and severe headaches may limit breastfeeding ability. Feedback: INCORRECT
Marie needs time to discover on her own what her limitations are. She may want to try breastfeeding in a reclined position, and this information may discourage her from even attempting it.
D) Indications and mechanism of action of caffeine sodium benzoate. Feedback: CORRECT
Prior to administering the medication, the nurse should explain that this medication is prescribed to constrict cerebral blood vessels and alleviate PDPH.
Points Earned:
1.0/1.0
Correct Answer(s):
D
The nurse starts the second unit of A negative blood, medicates Marie for pain, and encourages her to get some rest while the blood is infusing. Marie’s vital signs are stable, her fundus remains firm, located 1 cm below the umbilicus, and no reaction to the second unit of blood is noted. While Marie is resting, the blood bank calls and tells the nurse that Marie’s infant’s blood type is A positive, and the blood drawn from Marie after delivery indicates that she is indirect Coombs’ negative and non-sensitized.
23.
Based on this information, what is the correct nursing action? A) Obtain
RhoGam from the blood bank, and administer it as soon as possible. Feedback: INCORRECT
The negative indirect Coombs’ test indicates that Marie does need RhoGam since she has not yet developed sensitivity to the infant’s A positive antibodies. RhoGam prevents sensitization, but RhoGam administration guidelines state that it may be given any time within 72 hours of delivery. Since Marie is resting, the RhoGam doesn’t need to be given immediately.
B) Notify the healthcare provider and request a Coombs’ positive blood test for Marie and her infant. Feedback: INCORRECT
The serum Coombs’ test detects antibodies attached to red blood cells that may cause cellular damage. It is useful for diagnosing early if the infant is going to develop jaundice from exposure to the mother’s A negative antibodies during delivery. It is not done on the mother.
C) Document the findings in the client record, and pass the information on to the day shift. Feedback: INCORRECT
RhoGam could be delayed until the following day shift. However, since it must be administered within 72 hours of delivery, it is best if the nurse addresses the issue rather than pass it on to another shift.
D) Allow Marie to rest during the blood transfusion, and administer the RhoGam as prescribed at a later time. Feedback: CORRECT
The negative indirect Coombs’ test indicates that Marie has not yet developed sensitivity to the infant’s A positive antibodies. RhoGam prevents sensitization (antibody production to the + Rh factor), if administered within 72 hours of delivery. Since Marie is resting, the nurse can safely administer RhoGam at a later time within the 72-hour guideline.
Points Earned:
1.0/1.0
Correct Answer(s):
D
An Organizational Safety Issue
Marie’s husband comes to the nursing station and asks for an update on Marie’s condition. The nurse explains that Marie is resting while receiving her second unit of blood, her fundus is firm, vital signs are stable, and that she was able to use the bedpan to void. She tells the husband that when Marie sat up to void, she developed a severe migraine and is now being treated for PDPH. The nurse explains this disorder and the necessary treatment. The husband becomes frustrated and storms off the unit shouting, “I can’t believe you incompetent people here at this hospital! First you almost let my wife bleed to death, and now I find out that the idiot who put in the epidural catheter didn’t know what he was doing! Someone is going to pay for this!” Mr. Wilson goes into Marie’s room where she is breastfeeding the baby. Ten minutes later, the Infant Abduction alarm on the unit is activated, and the nurse sees Mr. Wilson walking out the door with an infant in his arms.
24.
What priority action should the nurse implement?
A) Request that pastoral care personnel locate the husband and discuss the issues. Feedback: INCORRECT
Pastoral counseling may be helpful during an upsetting event or crisis, but this is not the best practice in this situation. The husband’s anger can be addressed by a support professional later.
B) Notify the healthcare provider about the husband’s reaction and behavior. Feedback: INCORRECT
Although the healthcare provider should be notified of the incident, this is not the priority role of the nursing staff during this emergency response situation.
C) Notify the security personnel and direct all staff to report to their assigned exit in the hospital. Feedback: CORRECT
The security personnel and staff should be notified to respond to the abduction code. The husband is very upset and has violated a hospital policy
by taking the infant without following the proper discharge procedure and paternal identification policy.
D) Document the observation in the client record and submit an incident report to risk management. Feedback: INCORRECT
This is an important component in responding to this incident, but it is not the immediate response that needs to be implemented.
Points Earned:
1.0/1.0
Correct Answer(s):
C
Case Outcome
Security finds the husband in the waiting room talking on the phone with his brother. He visibly calms during the conversation. After speaking with security, Marie’s husband agrees to speak with the family liaison and hospital risk manager. The nurse stays with Marie and assesses her for the risk of intimate partner violence. Marie says she has never seen her husband like this and that he has never abused her verbally, physically, or sexually. The nurse gives Marie the number for the National Domestic Violence hotline in case she should ever need it. Four days later, Marie and her newborn are discharged home. Her husband and other children accompany her. Follow-up in one week is scheduled with Marie’s healthcare provider.
