A client is 1 hour postpartum from a vacuum delivery over a ...

[leilurhhh]

A client is 1 hour postpartum from a vacuum delivery over a midline episiotomy of a 4500-gram neonate. Which of the following nursing diagnoses is appropriate for this mother?
 
  a. Risk for altered parenting
  b. Risk for imbalanced nutrition: less than body requirements
  c. Risk for ineffective individual coping
  d. Risk for fluid volume deficit

Question 2

Which of the following sites is priority for the nurse to assess when caring for a breastfeeding client, G8 P5, who is 1 hour postdelivery?
 
  a. Nipples
  b. Fundus
  c. Lungs
  d. Rectum

[jazzlynnnnn]

Answer to Question 1

ANS: d
Feedback
a. Although the baby is macrosomic, there is no evidence that this mother is high risk for altered parenting.
b. This woman's baby is macrosomicthere is no indication that this woman is consuming a diet that is less than body requirements.
c. There is no evidence that this mother is high risk for altered coping.
d. This client is high risk for fluid volume deficit. Women who deliver macrosomic babies are high risk for uterine atony, which can lead to heavy flow of lochia.

Answer to Question 2

ANS: b
Feedback
a. Her nipples should be assessed, but this is not the priority assessment.
b. This client is a grand multipara. She is high risk for uterine atony and postpartum hemorrhage. The nurse should monitor her fundus very carefully.
c. Her lungs should be assessed bilaterally, but this is not the priority assessment.
d. Her rectum should be assessed for hemorrhoids, but this is not the priority assessment.