The nurse in charge is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client?
A. Risk for deficient fluid volume related to hemorrhage.
B. Risk for infection related to the type of delivery.
C. Pain related to the type of incision.
D. Urinary retention related to periurethral edema.
Correct Answer: A. Risk for deficient fluid volume related to hemorrhage
Hemorrhage jeopardizes the client’s oxygen supply — the first priority among human physiological needs. Therefore, the nursing diagnosis of Risk for deficient fluid volume related to hemorrhage takes priority over-diagnoses of Risk for Infection, Pain, and Urinary retention.
Option B: Episiotomy infections are classically reported as being rare at a rate of 0.1% and increasing up to 2% if a third or fourth-degree tear occurs.
Option C: Episiotomy pain may be relieved by an ice pack, warm or cold shallow baths or sitz baths, or medicated creams or local numbing sprays.
Option D: Postpartum urinary retention (PPUR) is an upsetting condition that has no standard literature definition. It has been variably defined as the abrupt onset of aching or inability to completely micturate, requiring urinary catheterization, over 12 hours after giving birth or not to void spontaneously within 6 hours of vaginal delivery.