A client who gave birth to her first child 12 hours ago has the following assessment findings: nauseated but has not vomited for two hours; boggy fundus that firmed with massage; moderately heavy lochia rubra; ecchymotic and edematous perineum; and
pain rating of 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. Acute Pain related to perineal trauma
2. Risk for Deficient Fluid Volume secondary to boggy fundus and nausea
3. Readiness for Enhanced Family Coping related to partner involvement
4. Deficient Knowledge related to birth of first child
2. Risk for Deficient Fluid Volume secondary to boggy fundus and nausea
Rationale:
Fluid volume is a critical physical issue and is therefore the highest priority nursing diagnosis. Although the nursing diagnosis acute pain fits, it is a lower priority than the risk of fluid volume deficit. Although the nursing diagnosis readiness for enhanced family coping fits, it is a lower priority thanthe risk of fluid volume deficit. Although the nursing diagnosis 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.
You might also like to view...
A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first?
a. Measure intake and output every 4 hours. b. Apply oxygen by mask or nasal cannula. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowler's position.
What characteristic best describes the language skills of a 3-year-old child?
a. Asks meanings of words b. Follows directional commands c. Can describe an object according to its composition d. Talks incessantly regardless of whether anyone is listening
The nurse is planning to administer a bitter-tasting oral medication to a 4-year-old. What strategy should this nurse plan?
A) Tell the child that the medication tastes good. B) Ask the parents how they give medications at home. C) Give the medication in orange juice or milk to mask the taste. D) Get another nurse to assist by holding the client down.
A client had a cesarean birth 3 days ago. She has tenderness, localized heat, and redness of the left leg. She is afebrile. As a result of these symptoms, what would the nurse anticipate would be the next course of action?
1. That the client would be encouraged to ambulate freely 2. That the client would be given aspirin 650 mg by mouth 3. That the client would be given Methergine IM 4. That the client would be placed on bed rest