HESI Case StudyPostpartum Exam 2024 Expected Questions and Answers (Verified by Expert)

HESI Case Study Postpartum Exam 2024 Expected Questions and Answers (Verified by Expert) HESI Case Study Postpartum Exam 2024 Expected Questions and Answers (Verified by Expert) HESI Case Study Postpartum Exam 2024 Expected Questions and Answers (Verified by Expert) 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 ANS: Uterine firmness. 2. 2. The postpartum client has minimal sensation in her lower extremities, due to the effects of the epidural anesthesia. What is the priority nursing concern for this client ANS: Fall risk. 3. 3. What is the priority nursing action to address the client's needs related to her repaired 4th degree perineal laceration ANS: 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 the postpartum unit. Where would the nurse expect to palpate the fundus ANS: 1 cm above 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 sheets beneath her saturated with blood. 5. Which action is most important for the nurse to implement immediately ANS: - Massage the fundus. 6. 6. What is the best method for the nurse to use to obtain immediate assis- tance ANS: Activate the priority call light from the bedside. 7. 7. The nurse has requested assistance and personnel are on their way. While waiting for help to arrive, what is the next priority action ANS: 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 delegated to the UAP during this crisis ANS: Obtain the vital signs and O2 saturation. 9. 9. The HCP is notified that the client is hemorrhaging and has an estimated blood 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%. The HCP's prescription includes stat oxytocin 10 units in each liter of normal saline to infuse at 40 milliunits (mU)/minute. How many mL of oxytocin should the nurse draw up in the syringe to inject into the 1000 mL bag of normal saline? (Enter numerical value only. If rounding is necessary, round to the tenth.): 1 10. 10. The HCP prescribed 0.2 mg of methylergonovine, and the vial contains 0.8 mg/mL. How many mL of methylergonovine should the nurse draw up in the syringe? (Enter numerical value only. If rounding is necessary, round to the hundredth.): 0.25 11. 11. The oxytocin has been infusing at the prescribed rate for 20 minutes. The nurse reassesses the client. 11. Which finding is most indicative that the medication is reaching a thera- peutic level ANS: Firm fundus. 12. 12. Postpartum hemorrhage is designated as blood loss in excess of 500 mL within the first 24 hours of delivery. Considering the client's history, what etiology is most likely ANS: Uterine atony. 13. The client is pale, weak, and anxious, but no longer disoriented. Her fundus is firm and is 1 cm above the umbilicus. Her bleeding has slowed considerably. The client tells the nurse that her spouse went home to pick up their other child to bring to the hospital. She states that she doesn't want her child to see her this way and asks the nurse to tell her spouse what has happened. 13. What intervention should the nurse implement to communicate the situa- tion to the client's spouse ANS: Call the spouse from the nurses' station to inform him of the client's status and request that the spouse come to the hospital soon, without the other child. 14. 14. What should the nurse do to prepare for the client's blood transfusion? (Select all that apply. One, some, or all options may be correct.): Start an additional IV using a 16 or 18 gauge angiocath. Prime a new Y-set blood tubing using a new bag of sodium chloride 0.9%. Obtain a baseline set of vital signs prior to starting the infusion. 15. The nurse is getting ready to administer the first unit of blood when the nursery nurse brings in the client's infant and states that the client needs to feed the baby because it has been 4 hours since the infant last nursed. The infant is sleeping soundly in the crib. 15. What is the best thing for the nurse to do ANS: Explain the client's history and request that the infant is fed with formula in the nursery. 16. 16. Prior to the blood transfusion, the nurse records the client's vital signs as T 97.8° F (36.6o C), heart rate 110 beats/min, respirations 22 breaths/min, and BP 78/50 mmHg. The blood requisition form, client identification bracelet, and blood label are checked with another nurse, and then the A negative blood transfusion is started at 75 mL/hr. Fifteen minutes after the transfusion begins, another set of vital signs is taken; T 98.5° F (36.9o C), heart rate 112 beats/min, respiration 22 breaths/min and B/P 76/48 mmHg. The client reports being cold. Which should the nurse do in response to these assessment findings ANS: Provide a warm blanket and continue to monitor the client.