A nurse who is called to a client's room notes that the client's cesarean incision has separated. Which of the following actions is the highest priority for the nurse to perform?

Correct Answer: B

Rationale: In this scenario, the highest priority action for the nurse is option B) Notify the surgeon. This is the correct answer because a separated cesarean incision is a serious complication that requires immediate attention by a healthcare provider, typically the surgeon who performed the cesarean section. Option A) Cover the wound with sterile wet dressings is incorrect because simply covering the wound will not address the underlying issue of the separation and delay in seeking appropriate medical intervention. Option C) Elevate the head of the client's bed slightly and option D) Flex the client's knees are also incorrect as they are not relevant or necessary in addressing a separated incision. Educationally, it is crucial for nurses and healthcare providers to recognize the significance of postpartum complications such as a separated incision and understand the appropriate steps to take in such situations to ensure the safety and well-being of the client. Prompt communication with the surgeon or healthcare provider is essential in managing postpartum complications effectively.

Correct Answer: B

Rationale: The correct nursing action in this scenario is option B, to dress the baby in a tee shirt and swaddle the baby in a receiving blanket. This action is appropriate because it allows the mother to spend time with her deceased baby, providing her with the opportunity for closure, bonding, and the chance to say goodbye. It respects the mother's emotional needs and supports the grieving process by acknowledging the baby as a significant part of her life and pregnancy. Option A is incorrect because it minimizes the mother's current loss and grief by redirecting her focus to a future pregnancy, which may invalidate her feelings of loss and sadness. It overlooks the immediate emotional needs of the mother. Option C is inappropriate as it suggests medicating the mother without assessing her emotional state or providing emotional support. Sedation should not be the first-line intervention for a bereaved mother. Option D is also incorrect as it disregards the mother's right to spend time with her deceased baby and denies her the opportunity for closure and grieving. In an educational context, it is crucial for nurses to understand the significance of supporting mothers who experience perinatal loss. Providing compassionate and sensitive care during such difficult times is essential for the emotional well-being of the mother. Nurses need to prioritize empathy, communication, and respect for the mother's choices and feelings in these situations.

Correct Answer: D

Rationale: In this scenario, the highest priority nursing diagnosis is "D) Pain." Postpartum women who have undergone a forceps delivery and an episiotomy are likely to experience significant pain and discomfort. Managing pain is crucial as it can affect the client's overall well-being, ability to ambulate, perform self-care activities, and establish bonding with the newborn. Option A, "Ineffective breastfeeding," may be a concern in the postpartum period, but addressing the client's pain takes precedence as unresolved pain can hinder successful breastfeeding. Option B, "Fluid volume deficit," is not the highest priority at this immediate postpartum stage unless there are specific indicators suggesting this issue. Option C, "Infection," is important to monitor for but does not take precedence over addressing the client's pain. Educationally, understanding the hierarchy of postpartum nursing care priorities is essential for providing safe and effective care to postpartum clients. Pain management is a fundamental aspect of care that can significantly impact the client's recovery and overall experience during the postpartum period. By prioritizing pain management, nurses can promote the client's comfort, mobility, and ability to engage in essential activities of daily living.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Absent bowel sounds. A paralytic ileus is a temporary paralysis of the bowel that can occur after abdominal surgery, including a cesarean section. Absent bowel sounds are a key indicator of a paralytic ileus because they suggest that peristalsis, the involuntary muscle contractions that move food through the digestive system, is not functioning properly. Option A) Abdominal striae are stretch marks on the skin and are not indicative of a paralytic ileus. Option B) Oliguria refers to decreased urine output and is not directly related to bowel function. Option C) Omphalocele is a congenital abdominal wall defect and is not a relevant assessment finding in this context. Educationally, understanding postpartum body changes, including potential complications like paralytic ileus, is crucial for healthcare providers caring for postpartum clients. Recognizing signs and symptoms early can help in prompt intervention and prevent complications. Nurses and midwives need to be skilled in assessing and managing postpartum women to ensure optimal recovery and well-being.

Correct Answer: C

Rationale: In this scenario, the nurse should assess patient C (PP3 from vacuum delivery with hemoglobin of 7.2 g/dL) first. This patient has a significantly low hemoglobin level, indicating a potential risk of postpartum hemorrhage and anemia, which require immediate attention to prevent complications like hypovolemic shock. Assessing and managing the patient's hemoglobin level is crucial for her well-being. Option A (PP1 with burning on urination) is a common issue postpartum and can be addressed after addressing more critical conditions. Option B (PP2 with blood loss of 500 mL at delivery) is concerning but occurred at delivery, so immediate intervention may not be required unless there are signs of ongoing hemorrhage. Option D (PP4 with firm and painful breasts) is likely experiencing engorgement, a common postpartum issue that can be addressed after addressing the more acute condition of severe anemia in patient C. This educational context highlights the prioritization of nursing care based on the urgency and potential severity of the patient's condition, emphasizing the importance of critical thinking and clinical judgment in prioritizing care in a postpartum setting. It also underscores the significance of understanding postpartum complications and their implications for maternal health.