HESI Case Study: Postpartum - Questions & Answers 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 ...
HESI Case Study: Postpartum 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. Assessment A 1, 000 mL bag of Lactated Ringer's solu tion 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. Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the nurse to obtain? uterine firmness 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. 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 epidura l anesthesia? Risk for injury The nurse performs the first assessment upon arrival to the postpartum unit. Where would the nurse expect to palpate the fundus? 1 cm above the umbilicus What is the priority nursing action to address Marie's needs r/t the r epair of her 4th degree perineal laceration? Apply perineal ice packs consistently for the first 24 to 48 hours. 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. Which action is most important for the nurse to implement immediately? Massage the fundus What is the best method for the nurse to use to obtain immediate assistance? Activate the priority call light from the bedside. The nurse has requested assistance and personnel are on their way. While waiting for help to arrive, what is the next priority action? Assess for bladder distention The charge nurse, two staff nurses, and an unlicensed assistive p ersonnel (UAP) rush in to assist the nurse with Marie. Which task is best delegated to the UAP during this crisis? Obtain VS and SpO2 The HCP is notified that Marie is hemorrhaging and has an estimated blood loss of 1,200 mL since delivery. Her blood pres sure is 70/40 mm Hg, Pulse 120, RR 28, SpO2 73%. The HCP's prescriptions include stat oxytocin (Pitocin) 10 units in each liter of normal saline to infuse at 40 milliunits/minute. The HCP also prescribes 0.2 mg methylergonovine maleate (Methergine) IM to b e given immediately. The vial of oxytocin (Pitocin) is labeled 20 units/mL. The vial of methylergonovine (Methergine) is labeled 0.8 mg/mL. How many mL of oxytocin (Pitocin) should the nurse draw up in the syringe to inject into the 1000 mL bag of NS? 0.5 How many mL of methylergonovine should the nurse draw up in the syringe to administer to Marie? 0.25 Initial Stabilization The oxytocin (Pitocin) has been infusing at the prescribed rate for 20 minutes. The nurse reassesses the client. Which finding is most indicative that the medication is reaching a therapeutic level? Firm fundus Postpartum hemorrhage is designated as blood loss in excess of 500 mL within the first 24 hours of delivery. Considering the client's history, what etiology is most likely? Uterine atony Marie is pale, weak, and anxious, but no longer disoriented. Her fundus is firm and is 1 cm above the umbilicus. She is receiving O2 per nasal cannula at 4 L/min and has a SpO2 of 88%. Her VS are BP 74/44, P 116, and RR 26. Her bleeding has s lowed 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.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller NurseHenny. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $10.49. You're not tied to anything after your purchase.
