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A nurse in a provider's office is caring for a 32-year-old female client who is pregnant.

Medical History:

The client is a Gravida 3 Para 2, at 32 weeks of gestation. She has a known allergy to penicillin. She is 5 feet 4 inches (163 cm) tall and weighs 178 lb (80.7 kg), with a BMI of 30.6. The client reports a 6 lb weight gain over the last 2 weeks. She has had a headache for 5 days, blurred vision, and dizziness, which Tylenol does not relieve. The client reports swelling of her feet and fingers. She has 2+ pitting edema of the lower extremities noted bilaterally, and swelling of the fingers and hands is noted. Deep tendon reflexes are 3+, absent clonus. Fetal heart tones (FHT) are 148/min.

Vital Signs:

0800:

Temperature: 36.6°C (97.9°F)

Pulse rate: 88/min

Respiratory rate: 20/min

Blood Pressure: 179/99 mm Hg

0815:

Pulse rate: 82/min

Respiratory rate: 16/min

Blood Pressure: 168/104 mm Hg

0830:

Pulse rate: 81/min

Respiratory rate: 16/min

Blood Pressure: 170/101 mm Hg

Querry: Which of the following assessment findings should the nurse report to the provider? (Select all that apply.)

A nurse is caring for a client who was admitted in preterm labor at 33 weeks gestation.
The provider has ordered betamethasone 12 mg IM every 24 hours.

A nurse is walking by a client's room and can hear the fetal heart rate dropping.
The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

A nurse in Labor and Delivery is caring for a client who just experienced SROM (spontaneous rupture of membranes) after her epidural. The client immediately states she is short of breath. The nurse lays the patient back and places oxygen on her when the client goes into complete cardiorespiratory failure.
The nurse should recognize that this client is experiencing which of the following obstetrical emergencies?

A nurse is caring for a 28-year-old female client in the fourth stage of labor after a vaginal delivery in the labor and delivery unit.
 

History and Physical: The client is a Gravida 3 Para 2 (T2P0A0L2) with chronic hypertension. She was admitted for medical induction of labor due to gestational diabetes with a Bishop score of 9 on admission. The plan was to induce labor with oxytocin.

Vital Signs:

1130:

• Blood Pressure: 144/92 mmHg
• Pulse: 99 bpm
• Respirations: 17/min
• Temperature: 100.4°F (38.0°C)
• Pulse Ox: 97%

Nurses Notes: At 1040, the client underwent a vacuum-assisted vaginal delivery of a viable female infant weighing 4215 grams. The placenta was manually extracted at 1035, appearing intact. At 1130, the fundus was boggy, midline, and at the umbilicus. Lochia rubra was heavy with small clots noted. The IV was patent and currently infusing ordered oxytocin.

Diagnostic Tests:

• Hemoglobin: 11g/dL (9.5-11 g/dL)
• Hematocrit: 33% (28-33%)
• White Blood Cell Count: 12,000/mm³ (5,600-17,000/mm³)
• Platelets: 151,000/mm³ (140,000-400,000/mm³)
• Protein Creatinine Ratio: 0.01 (less than 0.3)
• HbA1c: 8.9% (less than 5.7%)

Querry: Which of the following assessment findings require follow-up? Select All That Apply.

A nurse is caring for a 25-year-old postpartum female client who had a spontaneous vaginal birth at 39 weeks of gestation in the postpartum unit.

Medical History: The client is a Gravida 1, Para 1. She is currently breastfeeding.

Vital Signs:

• Blood Pressure: 120/80 mmHg
• Pulse: 80 bpm
• Respirations: 16/min
• Temperature: 36.8°C (98.2°F)
• Pulse Ox: 99%

Nurses Notes: The client reports feeling well overall. She is breastfeeding her newborn and has expressed concerns about her baby’s weight loss. The client’s breasts are full, warm, and slightly tender, indicating that her milk is coming in. She has been educated on breastfeeding and the expected changes in her baby's stool color. The client appears attentive and responsive to her baby’s needs. She is utilizing correct breastfeeding techniques and has been encouraged to continue feeding 8 to 12 times per day and on demand. The client has also been advised on the importance of monitoring her newborn's weight and intake.

Newborn Daily Weights:

• Birth weight: 3,515 gm (7 lb 12 oz)
• Weight after 24 hr: 3,410 gm (7 lb 8 oz) (3% weight loss)
• Weight after 48 hr: 3,345 gm (7 lb 4 oz) (5% weight loss)

Querry: Which of the following statements by the client indicates an understanding of the discharge teaching? Click to highlight the client statements that indicate an understanding of the discharge teaching.

A client suspects she is pregnant. The nurse is discussing the probable signs of pregnancy with the client.
Which of the following findings should the nurse include?

A nurse is caring for a newborn and observes signs of diaphoresis, jitteriness, and lethargy.
Which of the following actions should the nurse take?

A nurse is caring for a client in the fourth stage of labor after a vaginal delivery.

History and Physical:

BP: 144/92 mmHg.

Pulse: 99 bpm.
Respirations: 17/min.

Pulse Ox: 97%.

Temperature: 100.4 F (38.0 C).

Pain score: 1/10.

The nurse should first address the client's ____________ (assessment finding), followed by the client's ____________ (assessment finding).

A nurse is walking by a client's room and can hear the fetal heart rate dropping.
The nurse observes the heartbeat and interprets the monitor strip as indicating which of the following?

A nurse is caring for a newborn 4 hours after birth.
Which of the following actions should the nurse include in the plan of care to prevent jaundice?