Postpartum Case Study - Latest Verified Review
2024 Practice Questions and Answers for Exam
Preparation, 100% Correct with Explanations,
Highly Recommended, Download to Score A+
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most
important for the nurse to obtain? - Answers-Uterine firmness.
Oxytocin (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.
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? - Answers-Risk for injury.
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 two side-rails and instructing her to not get out of bed for
the first time without assistance.
What is the priority nursing action to address Marie's needs related to the
repair of her 4th degree perineal laceration? - Answers-Apply perineal ice
packs consistently for the first 24 to 48 hours.
Topical perineal ice packs cause local vasoconstriction, resulting in decreased
swelling and tissue congestion, preventing a hematoma, 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. A hematoma formation could contribute
to hypovolemia and needs to be prevented.
, Postpartum Case Study - Latest Verified Review
2024 Practice Questions and Answers for Exam
Preparation, 100% Correct with Explanations,
Highly Recommended, Download to Score A+
The nurse performs the first assessment upon arrival to the postpartum unit.
Where would the nurse expect to palpate the fundus? - Answers-1cm above the
umbilicus.
For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus.
You find Marie's sheets saturated in vaginal discharge of blood. What should
you do? - Answers-Massage the fundus.
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.
The nurse has requested assistance and personnel are on their way. While
waiting for help to arrive, what is the next priority action? - Answers-Assess
for bladder distention.
The client is 2 hours post-delivery with an IV infusion 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.
The charge nurse, two staff nurses, and unlicensed assistive personnel (UAP)
rush in to assist the nurse with Marie. Which task is best delegated to the UAP
during this crisis? - Answers-Obtain the vital signs and O2 saturation.
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
health care provider.
2024 Practice Questions and Answers for Exam
Preparation, 100% Correct with Explanations,
Highly Recommended, Download to Score A+
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most
important for the nurse to obtain? - Answers-Uterine firmness.
Oxytocin (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.
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? - Answers-Risk for injury.
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 two side-rails and instructing her to not get out of bed for
the first time without assistance.
What is the priority nursing action to address Marie's needs related to the
repair of her 4th degree perineal laceration? - Answers-Apply perineal ice
packs consistently for the first 24 to 48 hours.
Topical perineal ice packs cause local vasoconstriction, resulting in decreased
swelling and tissue congestion, preventing a hematoma, 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. A hematoma formation could contribute
to hypovolemia and needs to be prevented.
, Postpartum Case Study - Latest Verified Review
2024 Practice Questions and Answers for Exam
Preparation, 100% Correct with Explanations,
Highly Recommended, Download to Score A+
The nurse performs the first assessment upon arrival to the postpartum unit.
Where would the nurse expect to palpate the fundus? - Answers-1cm above the
umbilicus.
For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus.
You find Marie's sheets saturated in vaginal discharge of blood. What should
you do? - Answers-Massage the fundus.
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.
The nurse has requested assistance and personnel are on their way. While
waiting for help to arrive, what is the next priority action? - Answers-Assess
for bladder distention.
The client is 2 hours post-delivery with an IV infusion 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.
The charge nurse, two staff nurses, and unlicensed assistive personnel (UAP)
rush in to assist the nurse with Marie. Which task is best delegated to the UAP
during this crisis? - Answers-Obtain the vital signs and O2 saturation.
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
health care provider.
