HESI RN Case Study Postpartum Exam Questions
With Correct Answers
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most
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important for the nurse to obtain? - CORRECT ANSWER✔✔-C) Uterine firmness.
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Hormone used to stimulate uterine contractions and prevent hemorrhage from
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the placental site.
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Mari has minimal sensation in her lower extremities, die to the effects of the
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epidural anesthesia. What is the priority nursing diagnosis for Mari, who is
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experiencing residual effects of epidural anesthesia? - CORRECT ANSWER✔✔-A)
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Risk for injury.| |
Causes temporary loss of voluntary movement and muscle strength in the lower
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extremities. Serious injury could be incurred if Mari attempts to get out of bed on
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her own because her legs will be unable to sustain her weight.
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What is the priority nursing actions to address Mari's needs related to the repair
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of her 4th degree perineal laceration? - CORRECT ANSWER✔✔-C) Apply perineal
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ice packs consistently for the first 24 to 48 hours.
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Cause local vasoconstriction, resulting in decreased swelling and tissue
| | | | | | | | |
congestion, preventing a hematoma, as well as prmoting comfort. 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.
The nurse performs the first assessment upon arrival to the postpartum unit.
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Where would the nurse expect to palpate the fundus? - CORRECT ANSWER✔✔-D)
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1 cm above the umbilicus.
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For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus.
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Which action is most important for the nurse to implement immediately? -
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CORRECT ANSWER✔✔-A) Massage the fundus.
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Since a boggy fundus is the ost likely reason for this client's hemorrhaging,
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massaging the fundus is the most important intervention. The nurse should also
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call for assistance die to the amount of blood that has pooled unde the client.
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What is the best method for the nurse to use to obtain immediate assistance? -
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CORRECT ANSWER✔✔-C) Activate the priority call light from the bedside.
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The priority call light signals to the entire nursing unit that a client is in crisis. All
| | | | | | | | | | | | | | | | |
personnel available will respond to the distress signal.
| | | | | | |
The nurse has requested assistance and personnel are on their way. While waiting
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for help to arrive, what is the next priority action? - CORRECT ANSWER✔✔-C)
| | | | | | | | | | | | | |
Assess for bladder distention.
| | |
With Correct Answers
Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most
| | | | | | | | | | |
important for the nurse to obtain? - CORRECT ANSWER✔✔-C) Uterine firmness.
| | | | | | | | | |
Hormone used to stimulate uterine contractions and prevent hemorrhage from
| | | | | | | | | |
the placental site.
| |
Mari has minimal sensation in her lower extremities, die to the effects of the
| | | | | | | | | | | | | |
epidural anesthesia. What is the priority nursing diagnosis for Mari, who is
| | | | | | | | | | | |
experiencing residual effects of epidural anesthesia? - CORRECT ANSWER✔✔-A)
| | | | | | | | |
Risk for injury.| |
Causes temporary loss of voluntary movement and muscle strength in the lower
| | | | | | | | | | | |
extremities. Serious injury could be incurred if Mari attempts to get out of bed on
| | | | | | | | | | | | | |
her own because her legs will be unable to sustain her weight.
| | | | | | | | | | | |
What is the priority nursing actions to address Mari's needs related to the repair
| | | | | | | | | | | | | |
of her 4th degree perineal laceration? - CORRECT ANSWER✔✔-C) Apply perineal
| | | | | | | | | | |
ice packs consistently for the first 24 to 48 hours.
| | | | | | | | |
Cause local vasoconstriction, resulting in decreased swelling and tissue
| | | | | | | | |
congestion, preventing a hematoma, as well as prmoting comfort. 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.
The nurse performs the first assessment upon arrival to the postpartum unit.
| | | | | | | | | | | |
Where would the nurse expect to palpate the fundus? - CORRECT ANSWER✔✔-D)
| | | | | | | | | | |
1 cm above the umbilicus.
| | | | |
For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus.
| | | | | | | | | | | | | | |
Which action is most important for the nurse to implement immediately? -
| | | | | | | | | | | |
CORRECT ANSWER✔✔-A) Massage the fundus.
| | | |
Since a boggy fundus is the ost likely reason for this client's hemorrhaging,
| | | | | | | | | | | | |
massaging the fundus is the most important intervention. The nurse should also
| | | | | | | | | | | |
call for assistance die to the amount of blood that has pooled unde the client.
| | | | | | | | | | | | | |
What is the best method for the nurse to use to obtain immediate assistance? -
| | | | | | | | | | | | | | |
CORRECT ANSWER✔✔-C) Activate the priority call light from the bedside.
| | | | | | | | |
The priority call light signals to the entire nursing unit that a client is in crisis. All
| | | | | | | | | | | | | | | | |
personnel available will respond to the distress signal.
| | | | | | |
The nurse has requested assistance and personnel are on their way. While waiting
| | | | | | | | | | | |
for help to arrive, what is the next priority action? - CORRECT ANSWER✔✔-C)
| | | | | | | | | | | | | |
Assess for bladder distention.
| | |
