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A nurse is assisting with the care of a client who is in active labor.

The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

A nurse is reinforcing teaching with a client who is postpartum and receiving warfarin for deep-vein thrombosis. Which of the following instructions should the nurse include?

A nurse is reinforcing teaching with a mother who is bottle feeding her newborn with formula. Which of the following statements should the nurse include in the teaching?

A nurse is assisting with the care of a postpartum female client who delivered vaginally 8 hours ago in the maternity unit.

Exhibit 1: Vital Signs

0700:

• Temperature: 36.2°C (97.2°F)
• Heart rate: 80/min
• Respiratory rate: 16/min
• Blood pressure: 136/82 mm Hg

1100:

• Temperature: 37.2°C (99.0°F)
• Heart rate: 85/min
• Respiratory rate: 18/min
• Blood pressure: 136/86 mm Hg
• Pulse oximetry: 99%

Exhibit 2: Nurses' Notes

0700: The client's breasts were soft, and nipples were intact. The uterus was palpated as firm, midline, and at the level of the umbilicus. There was a moderate amount of lochia rubra. The episiotomy site was well approximated with mild edema and ecchymosis. The client reported pain as 2 on a scale of 0 to 10. She was able to void spontaneously, with no bladder distention. Deep tendon reflexes were 1+. Peripheral edema was 2+ in bilateral lower extremities.

1100: The client's breasts remained soft, and nipples were intact. The uterus was palpated as soft with lateral deviation and 1 cm above the umbilicus. There was a large amount of lochia rubra. The episiotomy site was well approximated with mild edema and ecchymosis. The client reported pain as 3 on a scale of 0 to 10. Deep tendon reflexes were 1+. Peripheral edema was 2+ in bilateral lower extremities.

Querry

Select the 3 findings that require immediate follow-up.

A nurse on the postpartum unit is caring for a client who delivered vaginally 3 hr ago. Which of the following manifestations is a possible indication of postpartum hemorrhage?

A nurse is assisting with the care of a client who received magnesium sulfate to treat preterm labor. The nurse should monitor the client for which of the following findings as an indication of magnesium sulfate toxicity?

A nurse is reinforcing teaching with a client who is in the first trimester of pregnancy about increasing their intake of foods that are high in folate. Which of the following should the nurse recommend as the food with the highest folate content?

A nurse is reinforcing teaching about perineal care to a client who is 2 hours postpartum and has an episiotomy and hemorrhoids. Which of the following statements by the client indicates understanding of the teaching?

A nurse is reinforcing preoperative teaching with a client who is scheduled for a cesarean birth. Which of the following client statements indicates an understanding of the teaching?

A nurse is reinforcing teaching with a client who is at 38 weeks of gestation and has a positive group B streptococcus B-hemolytic screening.

Which of the following medications should the nurse discuss as the prophylaxis treatment during labor for this client?

A nurse is caring for a client who is postpartum and has inverted nipples. Which of the following actions should the nurse take?