Take full exam for free

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 in the antepartum unit is caring for a client who is at 36 weeks of gestation and has preeclampsia. Suddenly, the client reports continuous severe abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications?

A nurse in Labor and Delivery is caring for a client who just experienced SROM (spontaneous rupture of membranes) after her epidural. The client immediately states she is short of breath. The nurse lays the patient back and places oxygen on her when the client goes into complete cardiorespiratory failure.
The nurse should recognize that this client is experiencing which of the following obstetrical emergencies?

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 is postpartum. The client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well.
Which of the following statements should the nurse make?

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 is caring for a client in labor at 39 weeks of gestation.
Which of the following assessment findings requires follow-up?

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 with irregular uterine contractions that are mild to palpation. FHR is 130/min with moderate variability and accelerations noted. The client has been ambulating in the hallway, took a warm shower, and is now resting in bed. The client rates pain of contractions at 3 on a 0 to 10 scale.
What potential condition does the nurse suspect?

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 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?