A client is 1 day post-cesarean section with spinal anesthesia. Even though the nurse advised against it, the client has had the head of her bed in high Fowler's position since delivery. Which of the following complications would the nurse expect to see in relation to the client's action?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Severe postural headache. When a client undergoes a cesarean section with spinal anesthesia, maintaining the head of the bed elevated can lead to a postural headache due to leakage of cerebrospinal fluid from the dural puncture site, exacerbated by the high Fowler's position. This positional headache is a common complication post-spinal anesthesia and can be severe. Option A) Postpartum hemorrhage is incorrect as it is not directly related to the client's position in bed. Postpartum hemorrhage usually occurs due to issues like uterine atony or retained placental fragments. Option C) Pruritic skin rash is also unrelated to the client's bed position and is more commonly associated with allergic reactions or dermatological conditions. Option D) Paralytic ileus is not typically caused by the client's bed position but rather by factors like decreased peristalsis following abdominal surgery. Educationally, this scenario highlights the importance of understanding the potential complications of specific postpartum interventions, like maintaining proper positioning post-cesarean section with spinal anesthesia to prevent avoidable issues such as postural headaches. It also emphasizes the need for clear patient education and compliance with healthcare provider instructions to ensure optimal recovery and outcomes.

Correct Answer: D

Rationale: In this scenario, option D is the correct answer. The nurse should be prepared to monitor client D closely for signs of postpartum hemorrhage (PPH) due to the risk factors associated with delivering a large-for-gestational-age baby at 42 weeks. Postpartum hemorrhage is more common in women who have delivered larger babies due to potential uterine atony or inability of the uterus to contract effectively after delivery. Additionally, the prolonged gestation increases the risk of uterine atony and subsequent PPH. Option A can be eliminated because delivering a fetal demise at 29 weeks does not typically increase the risk of PPH. Option B, a prolonged first stage of labor, may lead to exhaustion but is not a direct risk factor for PPH. Option C, a cesarean section for failure to progress, does not inherently increase the risk of PPH unless there are complications during or after the surgery. Educationally, understanding the risk factors for postpartum hemorrhage is crucial for nurses caring for laboring patients. By recognizing the factors that can contribute to PPH, nurses can provide appropriate monitoring, interventions, and support to prevent or manage this potentially life-threatening complication effectively.

Correct Answer: D

Rationale: In this scenario, the priority finding is option D) Client yells at the baby for crying. This behavior raises concerns about the client's mental and emotional well-being, as well as the potential for postpartum depression or other mental health issues. As a home care nurse, ensuring the safety and well-being of both the mother and baby is crucial. Option A) Lochia is serosa, while important, does not pose an immediate threat to the client or her baby's safety. Option B) Client cries throughout the visit may indicate emotional distress, but it is not as urgent as the potential risk of harm to the baby from the client yelling. Option C) Nipples are cracked is a common issue in breastfeeding mothers but does not take precedence over the safety of the baby in this situation. Educationally, this scenario highlights the importance of assessing not only physical but also mental health status in postpartum clients. It underscores the need for healthcare providers to be vigilant for signs of postpartum depression or other mental health concerns, as early intervention is key to ensuring the well-being of both the mother and baby. It also emphasizes the critical role of the nurse in providing holistic and comprehensive care to postpartum clients.

Correct Answer: B

Rationale: In this scenario, the highest priority nursing diagnosis is B) Infection. The client's presentation with a hard, red, warm nodule in the breast, elevated temperature, history of mastitis, and severe pain indicates a potential breast infection, which requires immediate attention to prevent further complications like abscess formation or sepsis. Option A) Ineffective breastfeeding is incorrect as the primary concern here is addressing the infection to ensure the client's health and safety. Option C) Ineffective individual coping may be a secondary concern once the infection is under control. Option D) Pain is important, but treating the underlying infection takes precedence. Educationally, it is crucial for nurses to prioritize nursing diagnoses based on the urgency of the client's condition. Understanding the signs and symptoms of infections like mastitis in breastfeeding clients is essential for early identification and intervention to prevent serious complications. Nurses must be prepared to act swiftly in cases of suspected infections to provide appropriate care and support to their clients.

Correct Answer: A

Rationale: In the postpartum period, uterine atony can lead to excessive bleeding and poses a risk for injury to the mother. Massaging the atonic uterus helps to promote uterine contractions and prevent further bleeding. The correct answer, option A) Moderate lochia flow, indicates an improvement in the client's condition. Lochia is the postpartum vaginal discharge containing blood, mucus, and uterine tissue. A moderate flow suggests that the uterus is contracting effectively to control bleeding. Option B) Decreased pain level, while important for the client's comfort, does not directly indicate an improvement in uterine atony. Option C) Stable blood pressure is a crucial parameter to monitor but may not specifically reflect the resolution of uterine atony. Option D) Fundus above the umbilicus is actually a concerning finding as it suggests uterine atony as the fundus should be firm and at or below the level of the umbilicus in the immediate postpartum period. Educationally, understanding the significance of uterine atony and its management postpartum is vital for nurses caring for postpartum clients. Recognizing the signs of uterine atony, implementing appropriate interventions like uterine massage, and evaluating outcomes such as lochia flow are essential skills in preventing postpartum complications.