Page 1 of 18
Postpartum HESI Case Study Exam 2025-2026 Review GRADED A+ QUESTIONS WIT H
CORRECT ANSWERS GRADED A+ 2025-2026 VERIFIED
Prior to the blood transfusion, the nurse records Marie's vital signs as T 97.8
degrees F (36.6 degrees C), BP 78/50 mmHg, P 110 beats/min, and R 22
breaths/min. 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 degrees F (36.9 degrees C), BP 76/48
mmHg, P 112 beats/min, and R 22 breaths/min. Marie complains of being cold.
What should the nurse do in response to these assessment findings?
A. Decrease the rate of the transfusion to 50 mL/hr.
B. Stop the transfusion and call the HCP.
C. Provide a warm blanket and continue to monitor.
D. Compare the blood type on the blood labels with the requisition forms.
C. Provide a warm blanket and continue to monitor.
Rationale:
The administration of cold blood commonly causes the client to feel cold, but it does
not constitute chills and fever, which are indicative of a febrile non-hemolytic
reaction.
Another Postpartum Complication
Marie complains that she developed a headache after she sat upright on the
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bedpan. She tells the nurse that the headache has lessened to a dull ache after
she has lain back down. The pain is intensified when she moves her head.
Considering Marie's history, what would be the most likely cause of Marie's
headache?
A. Oxygen administration (3 liters/nasal cannula).
B. Epidural anesthesia
C. Straining during delivery
D. Side effect of oxytocin (Pitocin)
B. Epidural anesthesia
Rationale:
Postdural puncture headache (PDPH) sometimes occurs after epidural anesthesia.
Its exact pathophysiology is uncertain, but it apparently stems from cerebrospinal
fluid (CSF) leakage at the puncture site, which causes a decrease in both CSF
volume and intracranial pressure.
Considering Marie's history and acuity level, who is the best nurse to assign to
Marie's care?
A. Registered nurse (RN) who has been licensed for 9 months.
B. Labor and delivery nurse with 12 years of experience, who was called in to
work for 4 hours until 2300.
C. Licensed practical nurse (LPN) with 15 years of postpartum/nursery
experience.
D. Charge nurse with 5 years of experience who oversees care during the night
shift and carries 1/2 of the client assignment load until 2300.
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B. Labor and delivery nurse with 12 years of experience, who was called in to work
for 4 hours until 2300.
Rationale:
This nurse is experienced with handling the acute needs of obstetrical clients and
would be a great resource for the next 4 hours in helping stabilize Marie's condition.
Marie, when more stabilized, could then be reassigned at 2300.
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 left forearm at 125 mL
per hour, with 300 mL remaining in the bag. The IV is patent, without redness
or swelling, and can be discontinued when this bag's infusion is complete.
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most
important for the nurse to obtain?
A. Vital signs
B. Vaginal discharge
C. Uterine firmness
D. Oral intake
C. Uterine firmness
Rationale:
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?
A. Risk for injury
B. Impaired physical mobility
Postpartum HESI Case Study Exam 2025-2026 Review GRADED A+ QUESTIONS WIT H
CORRECT ANSWERS GRADED A+ 2025-2026 VERIFIED
Prior to the blood transfusion, the nurse records Marie's vital signs as T 97.8
degrees F (36.6 degrees C), BP 78/50 mmHg, P 110 beats/min, and R 22
breaths/min. 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 degrees F (36.9 degrees C), BP 76/48
mmHg, P 112 beats/min, and R 22 breaths/min. Marie complains of being cold.
What should the nurse do in response to these assessment findings?
A. Decrease the rate of the transfusion to 50 mL/hr.
B. Stop the transfusion and call the HCP.
C. Provide a warm blanket and continue to monitor.
D. Compare the blood type on the blood labels with the requisition forms.
C. Provide a warm blanket and continue to monitor.
Rationale:
The administration of cold blood commonly causes the client to feel cold, but it does
not constitute chills and fever, which are indicative of a febrile non-hemolytic
reaction.
Another Postpartum Complication
Marie complains that she developed a headache after she sat upright on the
, Page 2 of 18
bedpan. She tells the nurse that the headache has lessened to a dull ache after
she has lain back down. The pain is intensified when she moves her head.
Considering Marie's history, what would be the most likely cause of Marie's
headache?
A. Oxygen administration (3 liters/nasal cannula).
B. Epidural anesthesia
C. Straining during delivery
D. Side effect of oxytocin (Pitocin)
B. Epidural anesthesia
Rationale:
Postdural puncture headache (PDPH) sometimes occurs after epidural anesthesia.
Its exact pathophysiology is uncertain, but it apparently stems from cerebrospinal
fluid (CSF) leakage at the puncture site, which causes a decrease in both CSF
volume and intracranial pressure.
Considering Marie's history and acuity level, who is the best nurse to assign to
Marie's care?
A. Registered nurse (RN) who has been licensed for 9 months.
B. Labor and delivery nurse with 12 years of experience, who was called in to
work for 4 hours until 2300.
C. Licensed practical nurse (LPN) with 15 years of postpartum/nursery
experience.
D. Charge nurse with 5 years of experience who oversees care during the night
shift and carries 1/2 of the client assignment load until 2300.
, Page 3 of 18
B. Labor and delivery nurse with 12 years of experience, who was called in to work
for 4 hours until 2300.
Rationale:
This nurse is experienced with handling the acute needs of obstetrical clients and
would be a great resource for the next 4 hours in helping stabilize Marie's condition.
Marie, when more stabilized, could then be reassigned at 2300.
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 left forearm at 125 mL
per hour, with 300 mL remaining in the bag. The IV is patent, without redness
or swelling, and can be discontinued when this bag's infusion is complete.
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most
important for the nurse to obtain?
A. Vital signs
B. Vaginal discharge
C. Uterine firmness
D. Oral intake
C. Uterine firmness
Rationale:
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?
A. Risk for injury
B. Impaired physical mobility
