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HESI RN EXIT 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. Thelabor 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 atthe bedside for delivery and appeared supportive.
- 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.
- 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 promotespositive client outcomes. Postpartum protocol requires that the nurse assessMarie'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 ofthe epidural anesthesia. What is the priority nursing diagnosis for Marie, whois experiencing residual effects of epidural anesthesia ANS: Risk for injury
- 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 theumbilicus
- 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 thefirst 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.
- The charge nurse, two staff nurses, and an unlicensed assistive personnel(UAP) rush in to assist the nurse with Marie. Which task is best delegated to the UAP during this crisis ANS: Obtain VS and SpO
- The HCP is notified that Marie is hemorrhaging and has an estimated bloodloss of 1, 200 mL since delivery. Her blood pressure is 70/4 0 mm Hg, Pulse 120, RR 28 , SpO 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 begiven 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 ofoxytocin (Pitocin) should the nurse draw up in the syringe to inject into the 1000 mL bag of NS ANS: 0.
- How many mL of methylergonovine should the nurse draw up in thesyringe to administer to Marie ANS: 0.
- Initial Stabilization: The oxytocin (Pitocin) has been infusing at the prescribedrate for 20 minutes. The nurse reassesses the client.
- Which finding is most indicative that the medication is reaching a thera-peutic level ANS: Firm fundus
- Postpartum hemorrhage is designated as blood loss in excess of 500 mLwithin the first 2 4 hours of delivery. Considering the client's history, what etiology is most likely ANS: Uterine atony 18. Marie is pale, weak, and anxious, but no longer disoriented. Her fundus isfirm and is 1 cm above the umbilicus. She is receiving O2 per nasal cannula at 4 L/min and has a SpO 2 of 88%. Her VS are BP 7 4/44, P 1 16, and RR 26. Herbleeding has slowed considerably.The nurse asks the UAP to bathe Marie andchange the bed linens.
Marie tells the nurse that her husband went home to pick up their other childto 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.:
- 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 otherchild.
- 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-matchis obtained.
- What should the nurse do to prepare for Marie's blood transfusion ANS: - Startan additional IV using a 16 to 18 gauge angiocath.
Blood 300 mL Total Intake 1 ,520 mL OUTPUT: Urine 500 mL (catheterized just prior to birth; 4 hrs ago)Bleeding 1,6 00 mL
Total Output 2,120 mL:
- What is the difference in Marie's intake and output ANS: 580
- The nurse is aware that Marie's condition is stabilizing. Which nursing intervention would be most appropriate at this time ANS: Palpate Marie's bladderfor fullness and catheterize if indicated. 28. Marie tells the nurse that she has sensation in her lower extremities, thatshe can move both her legs, and that she needs to use the bathroom. The nurse offers Marie the use of a bedpan or bedside commode. Marie replies
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.:
- 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.
- Considering Marie's history, what would be the most likely cause of Marie's headache ANS: Epidural anesthesia
- 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 2300.
- Delegation and Supervision: The nurse asks the unit clerk to page Marie'sHCP. While Marie's nurse is at the desk documenting Marie's shift summary andwaiting 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.
- 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
explains that the reason that Marie is experiencing sever migraines when she gets out of bed is because she has a postdural puncture headache (PDPH) that sometimes occurs after epidural anesthesia.
The decrease in intacranial pressure causes severe shifting of fluid, which causes the headache. The nurse explains that the headache and associated symptoms usually last 3 to 5 days. They will spontaneously resolve, but until they do, Marie willbe given pain mediation and placed on strict, reclined bed rest to limit her movement.
- Prior to administering the medications to Mari, which information should the nurse include about caffeine and sodium benzoate ANS: Caffeine and sodium benzoate will constrict the cerebral blood vessels and decrease the headache. 38. The nurse starts the second unit of A negative blood, medicates Marie for pain, and encourages her to get some rest while the blood is infusing. Marie'sVS are stable, her fundus remains firs, located 1 cm below the umbilicus, and no reaction to the second unit of blood is noted.
While Marie is resting, the blood bank calls and tells the nurse that Marie's infants blood type is A positive, and the blood drawn from Marie after deliveryindicates that she is indirect Coomb's negative and non-sensitized.:
- Based on this information, what is the correct nursing action ANS: Allow Marie to rest during the blood transfusion and administer the RhoGam as prescribed at alater time.
- An Organizational Safety Issue: Marie's husband comes to the nursing station and
asks for an update on Marie's condition. The nurse explains that Marie is resting while receiving her second unit of blood and that her fundus is firm, her VS are stable, and she was able to use the bedpan to void. She tells the husband that when Marie sat up to void, she developed a severe migraine and is now being treated for PDPH. The nurse explains this disorder and the necessary treatment.
The husband becomes frustrated and storms off the unit shouting, "I can't believe you incompetent people here at this hospital. First you almost let my wife bleed to death, and now I find out that the idiot who put in the epidural catheter didn't know what he was doing! Someone is going to pay for this!
Mr. Wilson goes into Marie's room where she is breastfeeding the baby. Ten minutes later, the Infant Abduction alarm on the unit is activated, and the nurse sees Mr. Wilson walking out the door with an infant in his arms.
- 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.
