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Zorluk: OrtaEstablishing Priorities

A nurse on a maternal-newborn unit is analyzing assessment data for clients who gave birth within the past 24 hours. Which of the following clinical findings require immediate follow-up by the nurse? Select all that apply.

  1. A client who saturated a perineal pad with bright red blood in 15 minutesCevap
  2. B
    A client who reports intense, intermittent uterine cramping while breastfeeding
  3. A client reporting a sudden onset of blurred vision and a severe headacheCevap
  4. D
    A client with a documented oral temperature of 100.2°F (37.9°C)
  5. A client exhibiting unilateral right calf swelling, erythema, and localized tendernessCevap
  6. F
    A client with a reported white blood cell (WBC) count of 20,000/mm³ (20 x 10^9/L)

Cevap

The findings requiring immediate follow-up are the saturated perineal pad in 15 minutes, the sudden onset of blurred vision with a severe headache, and the unilateral right calf swelling with erythema and tenderness.
The correct findings represent acute, unexpected complications of the postpartum period that directly threaten the client's life. A fully saturated pad in 15 minutes indicates acute postpartum hemorrhage (a primary circulation compromise). A severe headache with blurred vision points to severe preeclampsia, increasing the risk for stroke and eclamptic seizures. Unilateral calf swelling and erythema are classic manifestations of deep vein thrombosis (DVT), which can dislodge and cause a fatal pulmonary embolism. All three require immediate, prioritized action.

Adım Adım Çözüm

1
Evaluate each client's clinical presentation using the Airway, Breathing, Circulation (ABC) framework and the acute versus expected methodology.
Identify findings that are expected physiological adaptations to the postpartum period versus pathological complications.
Prioritization requires distinguishing normal, stable alterations from acute, life-threatening deteriorations.
2
Isolate the unexpected, high-risk findings.
The saturated perineal pad indicates hemorrhage (Circulation priority). The severe headache and blurred vision indicate severe preeclampsia (Neurological/Systemic priority). The unilateral calf swelling indicates a DVT (Circulation priority with pulmonary embolism risk).
These three clients face impending physiological instability and require rapid nursing interventions and provider notification.
3
Eliminate the expected physiological findings.
The uterine cramping during breastfeeding (afterpains), mild temperature elevation (dehydration/exertion), and leukocytosis (stress response) are all normal adaptations within the first 24 hours postpartum.
Stable, expected findings do not take precedence over acute, unstable conditions.

Anahtar Kavram

Prioritizing client care requires distinguishing between expected, stable physiological adaptations to a specific condition (e.g., postpartum state) and unexpected, acute complications that pose an immediate threat to life (e.g., hemorrhage, preeclampsia, deep vein thrombosis).
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Establishing Priorities

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