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Hesi Case Study Depression Answers

Post Partum HESI Case Study Essays

6121 WordsNov 6th, 201325 Pages

1.
Prior to discontinuing the IV Pitocin (oxytocin), which assessment is most important for the nurse to obtain?
A) Vital signs.
Feedback: INCORRECT
Vital sign assessment is important prior to discontinuing the Lactated Ringer's since the primary IV contributes to the maintenance of cardiovascular stability.

B) Vaginal discharge.
Feedback: INCORRECT
Expulsion of minimal bright red vaginal discharge is normal after delivery. It is difficult for the nurse to ascertain client stability merely by assessing the vaginal discharge and estimating amounts of vaginal blood loss.

C) Uterine firmness.
Feedback: CORRECT
Pitocin is a hormone used to stimulate uterine contractions and prevent hemorrhage from the placental site. Prior…show more content…

However, sitz baths are not encouraged until the 2nd or 3rd postpartum day, after the swelling has decreased. Promotion of increased circulation prior to this time will result in increased amounts of swelling, tissue congestion, and pain.

Points Earned:
1.0/1.0

Correct Answer(s):
C

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 minutes for the first hour and then every hour for the next three hours.

4.
Considering Marie's history, which postpartal complication is she most at risk for?
A) Deep vein thrombosis.
Feedback: INCORRECT
Venous thrombosis forms in response to inflammation in the vein wall as a result of venous stasis. Factors contributing to the development of deep vein thrombosis in the postpartum client include increased amounts of certain blood clotting factors, obesity, increased maternal age, high parity, prolonged inactivity, anemia, heart disease, and varicosities. Marie's history does not indicate any risk factors for deep vein thrombosis.

B) Subinvolution.
Feedback: INCORRECT
Subinvolution occurs when the uterus fails to follow the normal pattern of involution, but instead remains enlarged. It is caused by placental fragments

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1.
Prior to discontinuing the IV Pitocin (oxytocin), which assessment is most important for the nurse to obtain?
A) Vital signs.
Feedback: INCORRECT
Vital sign assessment is important prior to discontinuing the Lactated Ringer's since the primary IV contributes to the maintenance of cardiovascular stability.

B) Vaginal discharge.
Feedback: INCORRECT
Expulsion of minimal bright red vaginal discharge is normal after delivery. It is difficult for the nurse to ascertain client stability merely by assessing the vaginal discharge and estimating amounts of vaginal blood loss.

C) Uterine firmness.
Feedback: CORRECT
Pitocin is a hormone used to stimulate uterine contractions and prevent hemorrhage from the placental site. Prior…show more content…

Marie's history does not indicate any risk factors for subinvolution.

C) Endometritis.
Feedback: INCORRECT
Endometritis is a uterine infection, one of four types of puerperal (of or pertaining to childbirth) infections. Marie's history does not include any of the factors that contribute to increased risk for puerperal infection which are: poor nutritional status, anemia, vaginal infection with group B streptococcus, and diabetes.

D) Hemorrhage.
Feedback: CORRECT
Postpartal hemorrhage indicates loss of greater than 500 ml of blood after the end of the third stage of labor. Causes of early postpartal hemorrhage include uterine atony (relaxation of the uterus), laceration of the genital tract, and retained placental fragments. Factors in Maria's history that contribute to the potential for hemorrhage include: overdistention of the uterus due to a large infant, the trauma of a forceps delivery, a prolonged labor, and the use of oxytocin.

Points Earned:
1.0/1.0

Correct Answer(s):
D

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.

5.
What is the priority nursing action?
A) Take vital signs.
Feedback: INCORRECT
If the nurse takes the vital signs first, time will be lost while the client continues hemorrhaging.

B) Check the bladder.
Feedback:

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