Post Partum HESI Case Study Essays

6121 WordsNov 6, 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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