MEDizzy - Which of the following nursing diagnoses is the priority

Feed Library Learning Discuss Leaderboard Journal

The Multigravid Client in Labor

Which of the following nursing diagnoses is the priority after delivery for a multiparous client who received an epidural anesthetic?

ExplanationThe most appropriate diagnosis at this time is Risk for injury related to the effects of the epidural anesthesia because the client may have no sensation in her lower abdomen and legs for several hours postpartum. Care should be taken to avoid injury, and ambulation should be delayed until sensation has returned. No information is presented in the scenario to suggest Pain due to episiotomy and exhaustive pushing. Multiparous clients commonly have shortened labors and may not require an episiotomy. If the client did have an episiotomy and the epidural anesthetic has worn off, then this nursing diagnosis would be appropriate. Anxiety would apply if the client expressed feelings of anxiety or nervousness because of a problem with moving her legs or toes. Excess fluid volume would apply if the client received excessive amounts of intravenous fluid or complained of oliguria, an early sign of pulmonary edema.