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?

Question

Quizplus · Accepted Answer

The client's moderately heavy lochia and risk for fluid volume deficit, along with her nausea, are the highest priority because of the potential for hypovolemia and shock. Acute pain related to perineal trauma is also a concern but is not the highest priority. Readiness for Enhanced Family Coping and Knowledge Deficit related to newborn care are not immediate priorities at this time.

The Nurse Completes a Postpartum Assessment on a Client Who