Question

After receiving report at the beginning of the 0700 shift, the nurse must decide in what order the clients should be assessed. How would the nurse plan assessments? Arrange the clients in the order that they should be assessed. All options must be used. Drag the text in the left column to the correct order in the right column.

1. An 8-hour post-vaginal delivery gravida 2, para 2 client who is scheduled for a bilateral tubal ligation at 1200 today and has a continuous peripheral intravenous (IV) solution of 5% dextrose in lactated Ringer's solution (D5LR) with 20 milliunits of oxytocin (Pitocin) infusing at 125 mL/hr.
2. A 12-hour post-cesarean section delivery of a gravida 3, para 3, who reports a return of feeling in her lower extremities as well as a sensation of wetness underneath her buttocks.
3. A 48-hour post-cesarean section delivery of a gravida 1, para 1, who reports not yet having a bowel movement since delivery and requests a stool softener.
4. A 24-hour post-vaginal delivery of a gravida 4, para 4, who is complaining of abdominal cramping after nursing her baby and requesting ibuprofen (Motrin)."

Answer 1

1. A 12-hour post-cesarean section delivery of a gravida 3, para 3, who reports a return of feeling in her lower extremities as well as a sensation of wetness underneath her buttocks.

2. A 24-hour post-vaginal delivery of a gravida 4, para 4, who is complaining of abdominal cramping after nursing her baby and requesting ibuprofen (Motrin).

3. A 8-hour post-vaginal delivery gravida 2, para 2 client who is scheduled for a bilateral tubal ligation at 1200 today and has a continuous peripheral intravenous (IV) solution of 5% dextrose in lactated Ringer's solution (D5LR) with 20 milliunits of oxytocin (Pitocin) infusing at 125 mL/hr.

4. A 48-hour post-cesarean section delivery of a gravida 1, para 1, who reports not yet having a bowel movement since delivery and requests a stool softener.

Step-by-step explanation:

In prioritizing the assessments, the nurse must consider the acuity of each patient's condition and address immediate needs first. The client in the second position, a 12-hour post-cesarean section delivery of a gravida 3, para 3, reporting a return of feeling in her lower extremities and wetness underneath her buttocks, requires urgent attention to assess for possible complications such as hemorrhage or infection.

The third position is given to the 24-hour post-vaginal delivery of a gravida 4, para 4, experiencing abdominal cramping and requesting ibuprofen. While not as urgent as the second client, addressing pain and discomfort promptly is essential for patient comfort and recovery.

The fourth position is assigned to the 8-hour post-vaginal delivery gravida 2, para 2, scheduled for a bilateral tubal ligation at 1200 with a continuous IV solution. Although this client has a scheduled procedure, the other two clients require more immediate attention based on their reported symptoms.

Finally, the 48-hour post-cesarean section delivery of a gravida 1, para 1, who requests a stool softener, is placed last. This client's needs are important but not as time-sensitive as those of the other clients in the given scenario.

Prioritizing assessments in this manner ensures that the nurse addresses the most critical situations first while managing and optimizing care for all clients.