HESI RN Case Study: Postpartum

C) Uterine firmness. Hormone used to stimulate uterine contractions and prevent hemorrhage from the placental site.

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.

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.

D) 1 cm above the umbilicus. For the first 12 hours, the fundus should be 1 to 2 cm above the umbilicus.

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.

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.

C) 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 excesive bleeding. After the fundus is massaged, the bladder should be checked for distention.

D) Obtain the vital signs and O2 saturation. Both are within the scope of practice for the UAP, and the nurse should interpret thses findings as indications of hypovolemia due to blood loss and should also be report the findings to the HCP.

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D) Firm fundus. The desired therapeutic effect of oxytocin (Pitocin) is to cause potent and selective stimulation of uterine smooth muscle. A firm fundus indicates uterine contraction during the postpartum period, which is important to prevent further hemorrhage.

C) Uterine atony. The client's history revealed a prolonged labor (muscle fatigue) and a large baby (uterine overdistention). These are both frequent causes of uterine atony.

B) 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 other child.

B) Start an additional IV using a 16 to 18 gauge angiocath. C) Prime a new Y-set tubing using a new bag of normal saline. E) Obtain a baseline set of vital signs.

D) Explain Mari's history and request that the infant is fed with formula in the nursery. Condition is too unstable for her to fed her infant. Even though breastfeeding will stimulate uterine contractions, this is not as important as client stability.

C) Provide a warm blanket and continue to monitor. The administration of a cold blood bommonly causes the client to feel cold but it does not constitute chills and fever, which are indicative of a febrile nonhemolytic reaction.

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C) Palpate Mari's bladder for fullness and catheterize if indicated.

B) Epidural anesthesia. Postdural puncture headache (PDPH) sometimes occurs after wpidural anesthesia.

B) Labor and delivery nurse with 12 years of experience, who was called in to work for 4 hours until 2300. 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 Mari's condition. Mari, when more stabilized, could then be reassigned at 2300.

B) Mari's nurse, who has already given the shift report and is preparing to clock out. Off-going nurse has first hand information about her symptoms, should be the one to communicate with the HCP.

C) Obtain and document Mari's V/S.

A) Caffeine and sodium benzoate will constrict the cerebral blood vessels and decrease the headache. Prior to administering the medicaiton, the nurse should explain that this medicaiton is prescribed to constrict cerebral blood vesses and alleviate PDPH.

B) Allow Mari to rest during the blood transfusion and administer the PhoGam as prescribed at a later time.

A) Notify the security personnel and direct all staff to report to their assigned exit in the hospital.