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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 is caring for a client during the second trimester of pregnancy.After reviewing the client's blood work, the nurse notes the client is rubella non-immune.
When should the client be offered the rubella immunization?

A nurse is caring for a primigravida who asks about the function of the placenta.
Which of the following are functions of the placenta?

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 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 client who has a suspected ectopic pregnancy at 8 weeks of gestation.
Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?

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 receiving a report on a new postpartum admission. Her medical history includes chronic hypertension.
The client is asking about postpartum orders.

Which of the following would be contraindicated based on the client's medical history?

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?

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.