Marie Wilson, a 34-year-old female client who is gravida 4, para 3, is transferred to the postpartum unit two hours after a prolonged 14-hour labor and forceps delivery of a male infant weighing 9 lb, 2 oz. The placenta was intact upon delivery. The labor and delivery nurse reports that Marie was catheterized for 600 ml of yellow urine just before delivery. Her record indicates that she had a repair of a 4th degree laceration. A postpartum assessment reveals that her vital signs are stable: blood pressure 120/80, pulse 84, respirations 20, temperature 98.
9° F. Additional assessment indicates that her fundus is firm and located 1 cm above the umbilicus, and the perineal sutures are intact with edges well-approximated. The client describes herself as exhausted and without pain, since she has had no sensation below her waist since receiving epidural anesthesia.
A 1,000 ml bag of Lactated Ringer’s solution containing 10 units of Pitocin (oxytocin) is infusing via an 18 g peripheral IV in the left forearm at 125 ml per hour, with 300 ml remaining in the bag.
The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete. 1. Prior to discontinuing the IV Pitocin (oxytocin), which assessment is most important for the nurse to obtain?
A) Vital signs.
B) Vaginal discharge.
C) Uterine firmness.
D) Oral intake.
Correct answer(s): C
2. What is the priority nursing diagnosis for Marie, who is experiencing residual effects of epidural anesthesia?
A) Risk for injury.
B) Impaired physical mobility.
C) Altered urinary elimination.
D) Risk for infection.
Correct answer(s): A
3. What is the priority nursing action to address Marie’s needs related to the repair of her 4th degree perineal laceration? A) Provide prescribed oral pain medication and stool softener. B) Encourage warm sitz baths 2 to 3 times daily.
C) Apply perineal ice packs consistently for the first 24 to 48 hours. D) Teach proper and frequent use of the peri-bottle. Correct answer(s): C