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HESI RN EXIT CASE STUDY - POSTPARTUM
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 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 nurse finds Marie disoriented and
lying on her back in a pool of vaginal blood, with the sheets beneath her saturated with blood.
9. Which action is most important for the nurse to implement immediately
ANS: -
Massage the fundus
10. What is the best method for the nurse to use to obtain immediate assis- tance
ANS: Activate the priority call light from the bedside.
11. 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
74/44, P 116, and RR 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 other child to bring her 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.:
19. What intervention should the nurse implement to communicate the situa- tion to Marie's husband
ANS: 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 other child.
20. Blood Transfusion: The HCP prescribes 2 units of PRBC's to be transfused asap. Marie signs the
consent form, and a blood sample for the type and cross-match is obtained.
21. What should the nurse do to prepare for Marie's blood transfusion
ANS: - Start an additional IV using a 16 to 18 gauge angiocath.
- Prime a new Y-set tubing using a new bag of normal saline.
- Obtain a baseline set of vital signs.
22. Marie's nurse is getting ready to administer the first unit of blood when the nursery nurse brings
in Marie's infant daughter and states that Marie needs to feed her because it has been 4 hours since the infant last nursed. The infant is sleeping soundly in the crib.:
23. What is the best thing for Marie's nurse to do
ANS: Explain Marie's history and request that the infant is fed with formula in the nursery.
24. Prior to the blood transfusion, the nurse records Marie's VS at T 97.8. BP 78/50, P 110, RR 22. 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 VS is taken; T 98.5, BP 76/48, P 112, and RR 22. Marie complains of being cold. What should the nurse do in response to these assessment findings ANS: Provide a warm blanket and continue to monitor.
25. When the first unit of PRBCs is infused, the nurse performs a targeted assessment. Marie's
fundus remains firm and lochial flow has decreased to a small amount. Her VS are T 98.3, PB 96/58, P 92, and RR 22. Her SaO2 is 92% with 3 L of oxygen per nasal cannula. In preparation for shift change, the nurse calculates the intake and output for the past 4 hours as follows: INTAKE Oral 720 mL IV 500 mL Blood 300 mL Total Intake 1,520 mL OUTPUT: Urine 500 mL (catheterized just prior to birth; 4 hrs ago) Bleeding 1,600 mL Total Output 2,120 mL:
26. What is the difference in Marie's intake and output
ANS: 580
27. The nurse is aware that Marie's condition is stabilizing. Which nursing intervention would be
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.:
29. 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 she has lain back down. The pain is intensifies when she moves her head.
30. Considering Marie's history, what would be the most likely cause of Marie's headache
ANS: Epidural anesthesia
31. Considering Marie's history and acuity level, who is the best nurse to assign to Marie's care
ANS: Labor and delivery nurse with 12 years of experience, who was called in to work for 4 hours until
32. Delegation and Supervision: The nurse asks the unit clerk to page Marie's HCP. While Marie's
nurse is at the desk documenting Marie's shift summary and waiting for the HCP to return the page, the charge nurse asks for assistance in making client care assignments for the next shift. Marie's nurse gives the shift report and turns Marie's care over to the nurse who has been assigned to her care. As the nurse is preparing to leave for the evening, Marie's HCP calls, returning the page.
33. Who is the best person to speak with Marie's HCP
ANS: Marie's nurse, who has already given the shift report and is preparing to clock out.
34. The nurse notifies the HCP of Marie's status, including receiving the first unit of blood, current
VS, voiding 450 mL, and severe headache. The HCP confirms that since the migraine is postural in nature, Marie has a postdural puncture headache. The HCP request 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 every 6 hours IV, acetaminophen and codeine (Tylenol with Codeine #3) 1 to 2 tablets PO every 4-6 hours as needed for pain, and ondansetron (Zofran) 4 mg PO every 8 hours as need for nausea. Marie's nurse records the new prescriptions and reports them to the new nurse who is 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.:
35. Which task is best for the nurse to delegate to the UAP
ANS: Obtain and document Marie's VS
36. 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
alarm on the unit is activated, and the nurse sees Mr. Wilson walking out the door with an infant in his arms.
41. What priority action should the nurse implement
ANS: Notify the security per- sonnel and direct all staff to report to their assigned exit in the hospital.
42. 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 1 week is scheduled with Marie's HCP.
