The nurse receives the morning handoff report for a group of clients on the postpartum unit. In what order should the nurse assess these clients? Arrange the clients from highest priority (first to be seen) to lowest priority (last to be seen).
- 1A client who gave birth vaginally 2 hours ago and has a boggy fundus with heavy lochia rubra.
- 2A client who had a cesarean birth 24 hours ago and is requesting prescribed pain medication.
- 3A client who gave birth 12 hours ago and requires assistance with newborn latching for feeding.
- 4A client who is scheduled for discharge today and needs education on infant car seat safety.
Answer
Assess the client with a boggy fundus and heavy bleeding first, followed by the client requesting pain medication, then the client needing breastfeeding assistance, and finally the client requiring discharge teaching.
Prioritization in nursing follows established frameworks such as ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs. The client with a boggy fundus and heavy bleeding is experiencing a circulatory emergency (postpartum hemorrhage) and must be seen first to prevent hypovolemic shock. The client with acute postoperative pain is seen next to provide relief and prevent complications. The client needing assistance with breastfeeding has a functional, routine physiological need that should be addressed before the lowest-priority task, which is discharge teaching.
Step-by-Step Solution
Key Concept
Prioritization of care based on the ABCs (Airway, Breathing, Circulation) and Maslow's Hierarchy of Needs.