HESI RN EXIT CASE STUDY – POSTPARTUM 2024/2 UPDATE
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Course
HESI RN EXIT CASE
Institution
HESI RN EXIT CASE
HESI RN EXIT CASE STUDY – POSTPARTUM 2024/2 UPDATEHESI RN EXIT CASE STUDY – POSTPARTUM 2024/2 UPDATE
1. 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 deliv...
HESI RN EXIT CASE STUDY – POSTPARTUM 2024/2
UPDATE
1. 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.
2. 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.
3. Prior to discontinuing the IV oxytocin (Pitocin), which
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, assessment is most important for the nurse to obtain
ANS: uterine firmness
4. 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 mins. for the first hour and then every hour for the
next 3 hours.:
5. 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
6. 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
7. 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.
8. Postpartum Crisis: Fifteen minutes after the initial assessment, the
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