The nurse had completed a postpartum assessment on a patient who gave birth to her first child 12 hours ago. She is nauseated, but has not vomited in the last 2 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 patient?

Question

Quizplus · Accepted Answer

The patient's evidence of moderate uterine bleeding, combined with nausea, puts her at risk for deficient fluid volume. This is the highest priority nursing diagnosis as it could potentially lead to complications such as hypovolemic shock. The other options, while still important, are not as urgent. Acute pain related to perineal trauma would be addressed, but does not carry the same risk as fluid volume deficits. Readiness for enhanced family coping can be addressed after the patient's physical needs are stabilized, and knowledge deficit related to newborn care can be addressed at a later time as well.

The Nurse Had Completed a Postpartum Assessment on a Patient