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Difficulty: MediumEstablishing Priorities

A nurse on a postpartum maternity unit is prioritizing care for four assigned clients after receiving the morning shift report. Which client should the nurse evaluate first?

  1. A
    A client who gave birth vaginally 4 hours ago and has saturated one perineal pad over the last 2 hours.
  2. B
    A client who had a cesarean section 2 days ago and is requesting medication for incisional cramping rated 5 on a 0-10 scale.
  3. A client who gave birth 12 hours ago via cesarean section and is now reporting a sudden onset of shortness of breath and pleuritic chest pain.Answer
  4. D
    A client who gave birth vaginally 24 hours ago and reports bilateral breast engorgement and tenderness.

Answer

The client reporting a sudden onset of shortness of breath and pleuritic chest pain requires immediate evaluation.
The correct answer describes a client experiencing symptoms indicative of a pulmonary embolism, a highly acute and potentially fatal complication. According to the ABC (Airway, Breathing, Circulation) prioritization framework, any sudden alteration in respiratory or cardiovascular status demands immediate nursing assessment and intervention.

Step-by-Step Solution

1
Analyze each client's clinical presentation against the ABC (Airway, Breathing, Circulation) prioritization framework.
One client has a breathing and circulation compromise (shortness of breath, chest pain), while the others have expected postpartum findings.
The ABC framework is the primary tool for identifying life-threatening emergencies that require immediate intervention.
2
Differentiate between expected/chronic findings and unexpected/acute findings.
Lochia flow, incisional pain, and breast engorgement are expected findings. Sudden shortness of breath and chest pain are acute, unexpected complications.
Unexpected and acute physiological changes always take priority over routine or expected postoperative/postpartum symptoms.

Key Concept

Prioritization using the Airway, Breathing, Circulation (ABC) framework and acute versus expected findings.
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Topics

Establishing Priorities

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