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A nurse in a provider’s office is collecting data from a client who is at 34 weeks of gestation and reports having a sudden gush of vaginal fluid.Which of the following manifestations is the priority?

A nurse is contributing to the plan of care for a client who is postpartum and has mastitis.Which of the following actions should the nurse plan to take?

A nurse in a prenatal clinic is reinforcing teaching with a client who is at 20 weeks of gestation and has a low calcium level.Which of the following foods should the nurse recommend the client increase in her diet?

A nurse is reinforcing teaching about outpatient resources for a client who is recovering from a molar pregnancy.Which of the following statements by the client indicates an understanding of the teaching?

A nurse is collecting data from a client who is receiving epidural anesthesia.Which of the following findings indicates an adverse effect of this method of pain management?

A nurse is reinforcing teaching with a newly licensed nurse concerning a client on a postpartum unit following a cesarean birth.Which of the following measures should the nurse include in the instructions to prevent thrombophlebitis?

A nurse is assisting with the care of a postpartum client who delivered vaginally 8 hours ago in the maternity ward.

Exhibit 1: Vital Signs

0700:

• Temperature: 36.2°C (97.2°F)

• Heart rate: 80/min

• Respiratory rate: 16/min

• Blood pressure: 136/82 mm Hg

• Pulse oximetry: 99%

1100:

• Temperature: 37.2°C (99.0°F)

• Heart rate: 85/min

• Respiratory rate: 18/min

• Blood pressure: 136/86 mm Hg

• Pulse oximetry: 100%

Exhibit 2: Nurses’ Notes

0700: The client’s breasts are soft with intact nipples. The uterus is palpated firm, midline, and at the level of the umbilicus. There is a moderate amount of lochia rubra. The episiotomy site is well approximated with mild edema and ecchymosis. The client reports pain as 2 on a scale of 0 to 10. She is able to void spontaneously with no bladder distention. Deep tendon reflexes are 1+. Peripheral edema is 2+ in bilateral lower extremities.

1100: The client’s breasts are soft with intact nipples. The uterus is palpated soft with lateral deviation and 1 cm above the umbilicus. There is a large amount of lochia rubra. The episiotomy site is well approximated with mild edema and ecchymosis. The client reports pain as 3 on a scale of 0 to 10. Deep tendon reflexes are 1+. Peripheral edema is 2+ in bilateral lower extremities.

Question: Select the 3 findings that require immediate follow-up.

A nurse is reinforcing teaching with a client who is pregnant and reports frequent heartburn.Which of the following recommendations should the nurse include in the teaching?

A nurse is caring for a client who had a vaginal delivery 4 hours ago and reports perineal pain of 6 on a scale of 0 to 10. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client about common discomforts during the first trimester of pregnancy.Which of the following discomforts should the nurse include in the teaching?

A nurse is reinforcing teaching about breastfeeding with a client who is postpartum.Which of the following statements by the client indicates an understanding of the teaching?