Health Promotion and Maintenance
13. A client had a vaginal delivery 2 days ago. During the morning assessment, the client complains that excessive perspiration kept her awake all night. She is worried that there is a problem. Which response by a nurse would be the most appropriate?
. "You may be experiencing signs of infection."
. "Fluids that were retained during pregnancy are normally lost in this manner."
. "Maybe you drank too much fluid during the day."
. "IV fluids administered during labor sometimes cause sweating."
Test-Taking Tip
Consider why the client is asking the question—she is concerned about developing a problem; eliminate responses that do not address her concern.
Content Area: Maternity, Postpartum; Integrated Process: Communication and Documentation; Cognitive Level: Application; 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 this response could unnecessarily worry the client. Excessive perspiration may be a sign of infection, but there is no additional information in the stem that would lead to that possibility. Answer 2 is correct because this explanation is factually true. Fluids are retained during pregnancy and lost in this manner. This is called postpartum diuresis and is commonly experienced about 24 to 48 hours after delivery. Answer 3 is incorrect because speculating about the client's intake is not an appropriate response to her concerns. Answer 4 is incorrect because it assumes that the client had IV fluids administered during labor and does not address her concerns about having "a problem."