During change of shift report, the nurse hears the following information on a newly delivered client: 27 years old, married, G4 P3, 8 hours postspontaneous vaginal delivery over 3º laceration,
vitals—110/70, 98.6ºF, 82, 18, fundus firm at umbilicus, moderate lochia, ambulated to bathroom to void three times for a total of 900 mL, breastfeeding every 2 hours. Which of the following nursing diagnoses should the nurse include in this client's nursing care plan?
a. Fluid volume deficit
b. Impaired skin integrity
c. Impaired urinary elimination
d. Ineffective breastfeeding
ANS: b
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a. There is nothing in the scenario that indicates that this client has had a significant blood loss.
b. The client has a 3º laceration. A nursing diagnosis of impaired skin integrity is appropriate.
c. The client is voiding well. There is no indication of impaired urinary elimination.
d. The client is feeding q 2 h. There is no indication of impaired breastfeeding.
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