A nurse is caring for a postpartum client in an outpatient setting.

Exhibits

A nurse is caring for a postpartum client in an outpatient setting.

Complete the following sentence by using the lists of options.

The client is at highest risk for developing

evidenced by the client's

A. Incorrect. Encouraging the client to lie down in a quiet room is not specifically related to addressing auditory hallucinations.
B. Incorrect. Referring to hallucinations as if they are real can reinforce the client's delusions or hallucinations.
C. Incorrect. Avoiding eye contact can be perceived as dismissive or uninterested.
D. Correct. Asking the client directly about their hallucinations helps assess their content and severity, which is essential for developing an effective plan of care.

A. Placenta previa: The client's symptoms do not specifically suggest placenta previa, which is characterized by painless vaginal bleeding, not back pain.
B. Disseminated intravascular coagulation: The client's symptoms and vital signs do not suggest disseminated intravascular coagulation, which is a serious condition characterized by excessive bleeding and clotting throughout the body.
C. Preeclampsia: The presence of uterine contractions, elevated blood pressure, and a potential increase in body temperature can indicate the risk of developing preeclampsia, a condition characterized by high blood pressure and signs of damage to other organ systems, often developing after the 20th week of pregnancy.
D. Sepsis: While the client has an elevated temperature, the symptoms provided do not strongly indicate sepsis. Other signs, such as rapid heart rate, low blood pressure, and changes in mental status, are usually associated with sepsis.
E. Preterm prelabour rupture of membranes (PROM): The client's report of lower back pain, pinkish vaginal discharge, and uterine contractions can raise concern for the risk of preterm prelabour rupture of membranes, where the amniotic sac ruptures before the onset of labor.
F. Seizures: The client's symptoms and information provided do not indicate a risk of seizures. Seizures can be associated with conditions like preeclampsia but are not directly indicated by the client's current assessment.