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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?

The nurse is caring for a client at 39 weeks gestation in active labor. The client had a spontaneous rupture of membranes 2 hours ago with clear amniotic fluid noted. The client was 7 cm at the time of SROM. The nurse assesses the fetal heart rate monitor and identifies a fetal heart baseline of 145 bpm, with moderate variability, accelerations absent and recurrent variable decelerations.
Which of the following interventions should the nurse take? Select all that apply.

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 reviewing ways to prevent a TORCH infection during pregnancy with a group of newly licensed nurses.
Which statement by the nurse indicates understanding of the teaching?

A nurse is educating a client on breastfeeding positions.
Which of the following should the nurse discuss?

A client, at 6 weeks gestation, arrives at the OB clinic for her initial visit and requests to hear the fetal heartbeat.
What should the nurse include in the teaching regarding cardiac development?

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 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 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 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 nurse is assessing a newborn immediately following a scheduled cesarean delivery.
Which of the following assessments is the nurse's priority?