A client who is 3 weeks postpartum tells the nurse, “I am so tired all the time.
I didn’t realize having a baby would be this challenging.”. What should the nurse’s response be?

 

Choice A rationale

Cervical dilation is a sign of labor, but a dilation of 1 cm alone does not confirm active labor. It could be the early phase of labor or false labor.

Choice B rationale

Contractions that decrease with walking are typically associated with false labor. In true labor, contractions usually get stronger regardless of activity level.

Choice C rationale

While 2+ pitting edema in the lower extremities can be seen in pregnancy, it is not a reliable indicator of labor. It could be due to fluid retention or other conditions.

Choice D rationale

The status of the membranes (intact or ruptured) does not necessarily indicate whether a woman is in labor. Some women may experience membrane rupture before labor begins.

Choice A rationale

While nausea and vomiting can occur in the postpartum period, they are not the highest priority for a client with a history of rheumatic fever and heart damage. These symptoms are usually self-limiting and can be managed with antiemetics.

Choice B rationale

Fluid volume excess is the highest priority for a client with a history of rheumatic fever and heart damage. Rheumatic heart disease can result in impaired heart function, making it difficult for the heart to handle increased fluid volumes that occur during pregnancy and the postpartum period. This can lead to heart failure.

Choice C rationale

While sleep deprivation can occur in the postpartum period, it is not the highest priority for a client with a history of rheumatic fever and heart damage. Adequate rest is important for recovery, but it does not directly address the client’s risk of heart failure.

Choice D rationale

While infection is a concern in the postpartum period, it is not the highest priority for a client with a history of rheumatic fever and heart damage. While infection can exacerbate heart failure, the immediate concern is managing the client’s fluid volume to prevent heart failure.