A client has just given birth to a premature infant via emergency ...

[KimWrice]

A client has just given birth to a premature infant via emergency C-section. Which of the following nursing diagnoses would receive the lowest priority for the new mother?
 
  1. Acute pain, related to surgical procedure
  2. Impaired skin integrity, related to new incision
  3. Anxiety, related to unpredictability of newborn's health
  4. Risk for infection, related to surgical incision

Question 2

One of the diagnoses formulated for this client who recently experienced a CVA (cerebrovascular accident) is Risk for aspiration, related to neuromuscular dysfunction. Of the following interventions, which includes a rationale?
 
  1. Have suction equipment available at all times.
  2. Clear secretions from oral/nasal passageways as needed.
  3. Keep client in low-Fowler's position to prevent reflux.
  4. Provide frequent assessment for presence of obstructive material in mouth and throat.

[Chelseyj.hasty]

Answer to Question 1

Correct Answer: 4
Rationale 1: This option is an active problem and would receive a higher priority for care.
Rationale 2: This option is an active problem and would receive a higher priority for care.
Rationale 3: This option is an active problem and would receive a higher priority for care.
Rationale 4: A problem identified as potential (at risk for development) receives the lowest priority since it is currently not present.

Answer to Question 2

Correct Answer: 3
Rationale: A rationale is the scientific principle given as the reason for selecting a particular nursing intervention. It helps explain why an intervention would be implemented. This intervention does not explain why it is being done.

[KimWrice]

TYSM

[Alyson.hiatt@yahoo.com]

Excellent