A client who gave birth to her first child 12 hours ago has the following assessment findings: nausea for 2 hours; boggy fundus that firmed with massage; moderately heavy lochia rubra; ecchymotic and edematous perineum; and pain rating of 6 on scale of 1-

Question

The client's partner is present and supportive. Breastfeeding has been successful three times. Based on this data, which is the priority nursing diagnosis?
A) Acute Pain related to perineal trauma
B) Risk for Deficient Fluid Volume secondary to boggy fundus and nausea
C) Deficient Knowledge related to birth of first child
D) Readiness for Enhanced Family Coping related to partner involvement

Answer 1

Answer: B

Fluid volume is a critical physical issue and is therefore the highest-priority nursing diagnosis. Although the nursing diagnosis of Acute Pain fits, it is a lower priority than the risk of fluid volume deficit. Although the nursing diagnosis of Readiness for Enhanced Family Coping fits, it is a lower priority than the risk of fluid volume deficit. Although the nursing diagnosis of Deficient Knowledge fits, a knowledge deficit is a psychosocial issue and therefore a much lower priority than the critical physical diagnosis of risk for deficient fluid volume.