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A nurse is assessing a client who is 4 hours postpartum following a vaginal delivery.
Which of the following findings should the nurse identify as the priority?

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 with a new diagnosis of a vaginal fistula.
The client states, "I don't understand how I got this.”. Which of the following is a potential cause of a vaginal fistula?

A nurse is preparing to administer betamethasone 12mg IM to a client at 32 weeks gestation at risk for preterm delivery.
Betamethasone is available as 6mg/ml. How many ml will the nurse prepare for injection? (Use a leading zero, if it applies. Do not use a trailing zero)

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 4 hours postpartum following a vaginal delivery.
Which of the following findings should the nurse identify as the priority?

A client arrives at OB triage with complaints of decreased fetal movement for the past 24 hours.
The client states, "I see the high-risk clinic because I have chronic hypertension and gestational diabetes.”. The nurse applies the external fetal monitors and identifies a fetal heart rate baseline of 120 bpm, absent variability, no accelerations, and recurrent late decelerations.

What fetal heart rate category would the nurse communicate to the provider?

A client is concerned about needing a blood transfusion after delivery due to the blood loss in delivery. The nurse explains that blood volume increases during pregnancy. Which of the following is the correct percentage of increased blood volume during pregnancy that the nurse should explain to the client?

A nurse is caring for a newborn 1 hour following birth in the emergency unit. Medical History: The newborn was born at 39 weeks gestation via emergency cesarean section due to abruptio placenta and non-reassuring fetal heart rate. Apgar scores were 5 at 1 minute and 8 at 5 minutes. Positive pressure ventilation was given for 1 minute, followed by free flow oxygen.
Nurses' Notes: At 1000, the newborn was placed on a radiant warmer. The color is consistent with the newborn's genetic background, but acrocyanosis is present. Mild grunting, nasal flaring, and intermittent retractions are noted. The newborn appears restless and is being closely monitored. Vital Signs:Temperature: 36.6°C (97.9°F) Axillary Heart rate: 180/min Respiratory rate: 80/min Oxygen saturation: 96% Diagnostic Results:Hemoglobin: 9 g/dL (normal range: 14 to 24 g/dL)Hematocrit: 35% (normal range: 44% to 64%)Platelet count: 210,000/mm³ (normal range: 150,000 to 300,000/mm³)White blood cells: 9,500/mm³ (normal range: 9,000 to 30,000/mm³)Serum glucose: 38 mg/dL (normal range: 40 to 45 mg/dL)Querry: Select the 5 findings the nurse should report to the provider.Respiratory assessmentHemoglobinWhite blood cellsSerum glucoseTemperatureHeart rateHematocrit

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.