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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?

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 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 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 is caring for a client who is postpartum and finds the fundus boggy and displaced to the right.
Based on these findings, which of the following actions should the nurse take?

A nurse is caring for four newborns in a special care nursery.
Which of the following newborn assessment findings requires immediate intervention?

A nurse is walking by a client's room and can hear the fetal heart rate dropping.
The nurse observes the heartbeat and interprets the monitor strip as indicating which of the following?

A nurse on the labor and delivery unit is caring for a patient who is having induction of labor with oxytocin administered through a secondary IV line. Uterine contractions occur every 2 minutes, last 90 seconds each, and are strong to palpation. The baseline fetal heart rate is 150/min, with uniform decelerations beginning at the peak of the contraction, nadir after the peak of the contraction, and a return to baseline after the contraction is over.
Which of the following actions should the nurse take?

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 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 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?