HESI Case Study: Postpartum

What should the nurse do to prepare for Marie's blood transfusion?

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

How many mL of methylergonovine should the nurse draw up in the syringe to administer to Marie?

0.25

The HCP is notified that Marie is hemorrhaging and has an estimated blood loss of 1,200 mL since delivery. Her blood pressure is 70/40 mm Hg, Pulse 120, RR 28, SpO2 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 be given 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 of oxytocin (Pitocin) should the nurse draw up in the syringe to inject into the 1000 mL bag of NS?

0.5

The nurse performs the first assessment upon arrival to the postpartum unit. Where would the nurse expect to palpate the fundus?

1 cm above the umbilicus

What is the difference in Marie's intake and output?

580

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.

What is the best method for the nurse to use to obtain immediate assistance?

Activate the priority call light from the bedside.

Based on this information, what is the correct nursing action?

Allow Marie to rest during the blood transfusion and administer the RhoGam as prescribed at a later time.

What is the priority nursing action to address Marie's needs r/t the repair of her 4th degree perineal laceration?

Apply perineal ice packs consistently for the first 24 to 48 hours.

The nurse has requested assistance and personnel are on their way. While waiting for help to arrive, what is the next priority action?

Assess for bladder distention

Prior to administering the medications to Mari, which information should the nurse include about caffeine and sodium benzoate?

Caffeine and sodium benzoate will constrict the cerebral blood vessels and decrease the headache.

What intervention should the nurse implement to communicate the situation to Marie's husband?

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.

Considering Marie's history, what would be the most likely cause of Marie's headache?

Epidural anesthesia

What is the best thing for Marie's nurse to do?

Explain Marie's history and request that the infant is fed with formula in the nursery.

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.

Which finding is most indicative that the medication is reaching a therapeutic level?

Firm fundus

Considering Marie's history and acuity level, who is the best nurse to assign to Marie's care?

Labor and delivery nurse with 12 years of experience, who was called in to work for 4 hours until 2300.

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. The labor 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 at the bedside for delivery and appeared supportive.

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.

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.

Stabilization and Postpartum Care

Marie's new nurse prepares to administer the caffeine and sodium benzoate 0.5 g IV. She introduces herself to Marie and 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 will be given pain mediation and placed on strict, reclined bed rest to limit her movement.

Who is the best person to speak with Marie's HCP?

Marie's nurse, who has already given the shift report and is preparing to clock out.

Which action is most important for the nurse to implement immediately?

Massage the fundus

What priority action should the nurse implement?

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

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?

Obtain VS and SpO2

Which task is best for the nurse to delegate to the UAP?

Obtain and document Marie's VS

The nurse is aware that Marie's condition is stabilizing. Which nursing intervention would be most appropriate at this time?

Palpate Marie's bladder for fullness and catheterize if indicated.

Prior to the blood transfusion, the nurse records Marie's VS at T 97.8. BP 78/50, P 110, RR 22. The blood requisition form, client identification bracelet, and blood label are checked with another nurse, and then the A negative blood transfusion is started at 75 mL/hr. Fifteen minutes after the transfusion begins, another set of VS is taken; T 98.5, BP 76/48, P 112, and RR 22. Marie complains of being cold. What should the nurse do in response to these assessment findings?

Provide a warm blanket and continue to monitor.

Marie has minimal sensation in her lower extremities, due to the effects of the epidural anesthesia. What is the priority nursing diagnosis for Marie, who is experiencing residual effects of epidural anesthesia?

Risk for injury

Case Outcome

Security finds the husband in the waiting room talking on the phone with his brother. He visibly calms during the conversation. After speaking with security, Marie's husband agrees to speak with the family liaison and hospital risk manager. The nurse stays with Marie and assesses her for the risk of intimate partner violence. Marie says she has never seen her husband like this and that he has never abused her verbally, physically, or sexually. The nurse gives Marie the number for the National Domestic Violence hotline in case she should ever need it. Four days later, Marie and her newborn are discharged home. Her husband and other children accompany her. Follow-up in 1 week is scheduled with Marie's HCP.

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-match is obtained.

Delegation and Supervision

The nurse asks the unit clerk to page Marie's HCP. While Marie's nurse is at the desk documenting Marie's shift summary and waiting 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.

Initial Stabilization

The oxytocin (Pitocin) has been infusing at the prescribed rate for 20 minutes. The nurse reassesses the client.

Postpartum hemorrhage is designated as blood loss in excess of 500 mL within the first 24 hours of delivery. Considering the client's history, what etiology is most likely?

Uterine atony

Prior to discontinuing the IV oxytocin (Pitocin), which assessment is most important for the nurse to obtain?

uterine firmness