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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 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)

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 newborn with hyperbilirubinemia and is being treated with phototherapy.
For each of the following nursing actions, specify if it is indicated or contraindicated with phototherapy treatment.

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

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

A nurse is assessing a client's risk of breast cancer.
Which of the following would not be included in the education about risks?

A nurse is caring for a client who experienced a cesarean birth due to dysfunctional labor. The client states that she is disappointed that she did not have natural childbirth. Which of the following responses should the nurse make?
A. "It sounds like you are feeling sad that things didn't go as planned.”.

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?