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A nurse is assessing a client who is 2 hr postpartum and received spinal anesthesia for a cesarean birth.
Which of the following findings requires immediate intervention by the nurse?

A 38-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks gestation. Assessment findings include: blood pressure 140/90 mm Hg; pulse, 80 beats/min; respiratory rate, 16 breaths/min. The nurse suspects preeclampsia.
What additional finding would the nurse assess for?

A nurse is caring for a newborn client. The assessment findings include a high-pitched cry, increased muscle tone, frequent yawning, poor feeding with projectile vomiting, and tachypnea.
What condition does the nurse suspect?

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?

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 in the antepartum unit is caring for a client who is at 36 weeks of gestation and has preeclampsia. Suddenly, the client reports continuous severe abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?

A nurse is providing care to a woman who is at 36 weeks of gestation and in preterm labor with ruptured membranes.
The nurse determines that the client's oral temperature is 39.0 C (102.2 F). Besides notifying the provider, which of the following is an appropriate nursing action?

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 nurse in the labor and delivery unit is caring for a 31-year-old pregnant female client who is at 31 weeks of gestation.

History and Physical: The client is a Gravida 4 Para 3. She reports cramping and low back pain that started last night.

Vital Signs:

0900:

• Temperature: 36.9°C (98.4°F)
• Pulse rate: 87/min
• Respiratory rate: 20/min
• Blood Pressure: 129/70 mm Hg
• Oxygen saturation: 98%

1000:

• Pulse rate: 86/min
• Respiratory rate: 18/min
• Blood Pressure: 130/76 mm Hg
• Oxygen saturation: 97%

Nurses Notes: At 0900, the client was placed on a fetal monitor, and the fetal heart tones (FHT) were recorded at 160/min. The client reported pain as a 6 on a 0 to 10 scale and requested pain medication. Vaginal examination showed 2 cm dilation, 80% effacement, and -1 station. At 1000, uterine contractions were observed every 2 to 4 minutes, lasting 60 to 80 seconds, with an FHT of 155/min. Provider was notified of the client's status and assessment, and new orders were received.

Medical History: The client has a history of three previous pregnancies (Gravida 4 Para 3).Querry: The nurse is contacting the primary health care provider regarding the client's status.

Which of the following interventions should the nurse anticipate? Select the 3 interventions the nurse should anticipate.

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 in the newborn nursery is caring for a group of newborns.
Which of the following assessments requires the nurse to notify the provider?