HESI RN EXIT CASE STUDY - POSTPARTUM

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HESI RN EXIT CASE STUDY - POSTPARTUM

• Meet the Client: Marie Wilson: Marie Wilson is a 28-year-old client who is

gravida 2, para 2, and is transferred to the postpartum unit 1 hour after delivery of a 8 lb, 1 oz female. She was in labor for 16 hours and forceps were used to assist with the delivery. Marie was given an epidural for anesthesia that was effective. The labor and delivery nurse reported that Marie had a 4th degree laceration and her pain was currently at a 3 out of 10 scale. Her vital signs were stable and she was catheterized for 500 mL of light yellow urine just prior to delivery. Mr. Wilson was at the bedside for delivery and appeared supportive.

• Assessment: 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 LFA at 125 mL/hr, with 300 mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinues when the bag's infusion is complete.

• Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most

important for the nurse to obtain

ANS: uterine firmness

• Early detection of, and intervention for, postpartum complications promotes 1 / 2

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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 mins. for the first hour and then every hour for the next 3

hours.:

• 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

ANS: Risk for injury

• The nurse performs the first assessment upon arrival to the postpartum

unit. Where would the nurse expect to palpate the fundus

ANS: 1 cm above the umbilicus

• What is the priority nursing action to address Marie's needs r/t the repair of

her 4th degree perineal laceration

ANS: Apply perineal ice packs consistently for the first 24 to 48 hours.

• 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.

• Which action is most important for the nurse to implement immediately

ANS: -

Massage the fundus

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