The nurse had completed a postpartum assessment on a client who gave birth to her first child 12 hours ago. She is nauseated, but has not vomited in the last two 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 client? 1. Pain [acute] related to perineal trauma
2. Fluid Volume, risk for deficit secondary to boggy fundus and nausea
3. Family Coping, readiness for enhanced related to partner involvement
4. Knowledge, deficit related to birth of first child
2
Rationale:
1. Although this nursing diagnosis fits, pain is a lower priority than risk for fluid volume deficit.
2. Fluid volume is a critical physical issue; therefore, this is the highest-priority nursing diagnosis.
3. Although this nursing diagnosis fits, family coping is a lower priority than risk for fluid volume deficit.
4. Although this nursing diagnosis fits, a knowledge deficit is a psychosocial issue, and therefore a much lower priority than the critical physical diagnosis risk for fluid volume deficit.
You might also like to view...
An adult female says, "I don't need contraceptives, because my cycles are as regular as clockwork. I know when I should abstain from intercourse, because I do not want to get preg-nant." Select the nurse's best response
a. "You are fortunate that your cycles are so regular. Most women are unable to rely on this approach to contraception." b. "You are still at risk for getting a sexually transmitted disease. Let's discuss con-traceptive options that will prevent disease." c. "Many factors can change the menstrual cycle. You're fortunate to have regular cycles, but an additional method of contraception should be used to prevent pregnancy." d. "You have described the rhythm method of contraception. Women have used that method successfully for thousands of years."
The patient has an indwelling catheter in place following a TURP. What instructions will the nurse give to the UAP with regards to the catheter?
A. Secure the catheter so there is no tension B. Irrigate the catheter to prevent clotting C. Maintain traction on the catheter D. Defer catheter care until the patient is discharged
A physically frail elderly patient with mild cognitive impairments needs services of a facility that can provide supervision, safety, and recreational and social interaction during the day. Family cares for the patient during the evening and night
Which type of facility would meet this patient's needs? a. Adult day care program b. Skilled nursing facility c. Partial hospitalization d. Psychotherapy group
A client states she is experiencing high stress. She is in a work environment in which her boss treats
her "like a doormat.". She states he thinks nothing of demanding that she stay overtime and work on Saturdays whenever he is "in the mood to work.". A coping strategy the nurse might suggest using is a. resigning the position. b. learning to reframe the situation. c. relying on the support of her family. d. using assertiveness techniques.