Post Partum HESI Case Study Essays

6122 Words Nov 25th, 2013 25 Pages
Prior to discontinuing the IV Pitocin (oxytocin), which assessment is most important for the nurse to obtain?
A) Vital signs.
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.
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
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Marie's history does not indicate any risk factors for subinvolution.

C) Endometritis.
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:

Correct Answer(s):

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.

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

B) Check the bladder.

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