A client is admitted to the postpartum unit and tells the nurse she had rheumatic fever as a child, which resulted in some "heart damage." The nurse knows that this client is at particular risk for developing heart failure during the immediate postpartum period. Based on this client's history, which nursing problem has the highest priority?
Sleep deprivation.
Fluid volume excess
Nausea and vomiting
Risk for infection.
The Correct Answer is B
A. Sleep deprivation:
While sleep is important for overall well-being, it may not be the top priority in this case. Fluid volume excess, given the client's cardiac history, poses a more immediate threat to health.
B. Fluid volume excess:
Clients with heart damage are prone to heart failure, and managing fluid balance is crucial. Excess fluid can worsen cardiac function, making this the priority concern.
C. Nausea and vomiting:
While nausea and vomiting are significant concerns, they might not be as directly related to the client's cardiac history as fluid volume excess. However, if severe, it could contribute to fluid imbalance.
D. Risk for infection:
Infection is a concern for postpartum clients, but in this case, the client's history of rheumatic fever and heart damage takes precedence. The priority is to prevent complications related to heart failure.
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Related Questions
Correct Answer is D
Explanation
A. Unilateral lower leg pain:
Unilateral lower leg pain can be a symptom of deep vein thrombosis (DVT), which is a serious condition. It requires further assessment and intervention.
B. Soft, spongy fundus:
A soft, spongy fundus is not a normal finding 12 hours postpartum. The fundus should be firm and well-contracted. A soft fundus could indicate uterine atony, a potential cause of postpartum hemorrhage.
C. Saturating two perineal pads per hour:
Saturating two perineal pads per hour is not a normal finding and may indicate excessive bleeding, which is concerning for postpartum hemorrhage. This requires immediate attention.
D. Pulse rate of 56 beats/minute:
A pulse rate of 56 beats per minute can be within the normal range, especially if the client is at rest. However, it's essential to consider the overall clinical picture and whether there are any signs of distress or symptoms associated with a low pulse rate.
Correct Answer is A
Explanation
Prepare for a cesarean section:Active herpes lesions are a contraindication for vaginal delivery due to the risk of transmitting the herpes simplex virus (HSV) to the newborn. A cesarean section is necessary to prevent the baby from coming into direct contact with the herpes lesions and reduce the risk of neonatal herpes infection.
Cover the lesion with a dressing:While covering the lesion might be part of overall care, it does not address the primary concern of preventing transmission to the newborn during delivery.
Obtain blood cultures:
Obtaining blood cultures may not be the primary action in this situation. The concern is more related to preventing the transmission of the herpes virus to the newborn.
Administer penicillin:
Penicillin is not the treatment for herpes. Antiviral medications such as acyclovir are typically used for the treatment of herpes infections.
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