A nurse calls a client who was discharged 3 days ago after a… | MyMerci
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Health Promotion and Maintenance

A nurse calls a client who was discharged 3 days ago after a vaginal delivery. The client reports, "I've had a pounding headache since last night and my vision is blurry." Which response by the nurse is most appropriate?

Chart/Exhibit

Choose your responses, then check the answer.

History
Vitals
Labs
Orders
Notes
G2P2, vaginal delivery 3 days ago, uncomplicated pregnancy, no chronic conditions.
BP 150/98 mmHg at discharge, HR 88, RR 16, T 98.6°F.
Hgb 11.2 g/dL, Hct 34%, platelets 210,000/µL.
Discharge instructions: monitor for warning signs, follow-up in 2 weeks.
Client reports severe headache and blurred vision since last night. Denies chest pain or heavy bleeding.
Explanation
A severe headache with vision changes after delivery is an urgent maternal warning sign that may indicate preeclampsia or other serious conditions. The client needs immediate evaluation in the emergency department, not self-care or routine follow-up. Advising ibuprofen and rest delays necessary care and could be dangerous. Telling the client it is common and will resolve ignores the potential severity. Scheduling a follow-up appointment this week does not address the urgency of the symptoms.
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