# 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?

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> language: en  
> subject: Health Promotion and Maintenance  
> category: HPM

## Question

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?

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.

1

"Take ibuprofen and rest in a dark room; call back if it persists."

✕

2

"This is common after delivery; it should resolve on its own."

✕

3

"Come to the emergency department immediately for evaluation."

✕

4

"Schedule a follow-up appointment with your obstetrician this week."

✕

## 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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