The nurse had completed a postpartum assessment on a patient who gave birth to her first child 12 hours ago. She is nauseated, but has not vomited in the last 2 hours
Her fundus was boggy, and firmed with massage to 1 FB ? U, moderately heavy lochia rubra, perineum ecchymotic and edematous, and pain rating 6 on scale of 1–10. Her partner is present and supportive. Breastfeeding has been successful three times. Which nursing diagnosis has the highest priority for this patient?
1. Acute pain related to perineal trauma
2. Risk for deficient fluid volume related to uterine bleeding and nausea
3. Readiness for enhanced family coping
4. Knowledge deficit related to newborn care
Correct Answer: 2
Rationale 1: Although this nursing diagnosis is applicable, pain is a lower priority than is risk for fluid volume deficit.
Rationale 2: Adequate fluid volume is a critical Physiological need; therefore, this is the highest-priority nursing diagnosis.
Rationale 3: Although this nursing diagnosis may be applicable, family coping is a lower priority than is risk for fluid volume deficit.
Rationale 4: Although this nursing diagnosis may be applicable, a knowledge deficit is a psychosocial issue, and therefore a lower priority than is the Physiological need for adequate fluid volume.
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