The nurse completes a postpartum assessment on a client who gave birth to her first child 12 hours ago
Assessment findings include: the client nauseated, but has not vomited in the last 2 hours; fundus was boggy but firmed with massage to 1 FB ? the uterus; client is experiencing moderately heavy lochia rubra and the perineum ecchymotic and edematous. The client's pain rating is 6 on scale of 1 to 10. Her partner is present and supportive. Breastfeeding has been successful 3 times. Which nursing diagnosis has the highest priority for this client? 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 related to vaginal childbirth experience
4. Knowledge Deficit related to newborn care
2
Explanation:
1. Although this nursing diagnosis is applicable, pain is a lower priority than is risk for fluid volume deficit.
2. Adequate fluid volume is a critical physiologic need; therefore, this is the highest-priority nursing diagnosis.
3. Although this nursing diagnosis may be applicable, family coping is a lower priority than is risk for fluid volume deficit.
4. Although this nursing diagnosis may be applicable, a knowledge deficit is a psychosocial issue, and therefore a lower priority than is the physiologic need for adequate fluid volume.
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A) Begin the session with the implications of inadequate learning. B) Provide current written learning materials. C) Begin the session with a reference to the client's actual experience. D) Talk to the client's relatives and get a detailed account of the client's history.
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1. Vocational Rehabilitation Act of 1920. 2. Social Security Act of 1935. 3. Rehabilitation Act of 1973. 4. Americans with Disabilities Act of 1990.
When educating a breast-feeding mother on the characteristic of the stool of her newborn, the nurse should inform her that the stool will be:
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Which of the following recommendations should a nurse give a client with a sexually transmitted disease who is at risk of infection transmission?
A) Pat the skin dry. B) Have regular cancer screening examinations. C) Have early prenatal care if pregnant. D) Bathe regularly.