Health Promotion and Maintenance
65. A client, who is gravida 3, para 2, has a spontaneous vaginal delivery of a 6-pound baby girl over an intact perineum. She has an epidural for relief of labor pain. She is currently in the fourth stage of labor. Which nursing goal would be most appropriate for the client at this time?
. The client's episiotomy will remain clean, dry, and intact.
. The client will turn, cough, and deep breathe 10 times an hour.
. The client will ambulate in the room without assistance.
. The client will maintain physiological homeostasis.
Test-Taking Tip
The question states the client has an intact perineum; therefore, eliminate the obvious answer that discusses an episiotomy (Answer 1). Choose the answer with the most general content (i.e., physiological homeostasis), rather than specific behaviors (i.e., "turn, cough . . ." and ". . . ambulate without assistance").
Content Area: Maternity, Postpartum; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care
Health Promotion and Maintenance
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Answer 1 is incorrect because the client doesn't have an episiotomy. Answer 2 is incorrect because pulmonary hygiene is important in clients with a respiratory condition, or those who have undergone a cesarean section. Answer 3 is incorrect because epidural anesthesia takes approximately an hour to wear off. The client will be unable to ambulate during this time. In addition, all clients who are postpartum should be assisted with ambulation the first few times out of bed. Answer 4 is correct because maintaining physiological homeostasis is the most important goal during the fourth stage of labor, the immediate postpartum period. The most common complication of the fourth stage of labor is uterine atony and hemorrhage.