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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 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 caring for a client who is on the electronic fetal monitor and the nurse notices that the client is experiencing tachysystole.
Which of the following describes tachysystole?

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 is assessing a client who is 2 hr postpartum and received spinal anesthesia for a cesarean birth.
Which of the following findings requires immediate intervention by the nurse?

A nurse is caring for a 25-year-old postpartum female client who had a spontaneous vaginal birth at 39 weeks of gestation in the postpartum unit.

Medical History: The client is a Gravida 1, Para 1. She is currently breastfeeding.

Vital Signs:

• Blood Pressure: 120/80 mmHg
• Pulse: 80 bpm
• Respirations: 16/min
• Temperature: 36.8°C (98.2°F)
• Pulse Ox: 99%

Nurses Notes: The client reports feeling well overall. She is breastfeeding her newborn and has expressed concerns about her baby’s weight loss. The client’s breasts are full, warm, and slightly tender, indicating that her milk is coming in. She has been educated on breastfeeding and the expected changes in her baby's stool color. The client appears attentive and responsive to her baby’s needs. She is utilizing correct breastfeeding techniques and has been encouraged to continue feeding 8 to 12 times per day and on demand. The client has also been advised on the importance of monitoring her newborn's weight and intake.

Newborn Daily Weights:

• Birth weight: 3,515 gm (7 lb 12 oz)
• Weight after 24 hr: 3,410 gm (7 lb 8 oz) (3% weight loss)
• Weight after 48 hr: 3,345 gm (7 lb 4 oz) (5% weight loss)

Querry: Which of the following statements by the client indicates an understanding of the discharge teaching? Click to highlight the client statements that indicate an understanding of the discharge teaching.

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.”.

You admitted a client who experienced a precipitous labor.
What is the highest concern for maternal complication related to this type of labor?

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 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?

A nurse is admitting a client in labor who is HIV positive.
Which intervention is contraindicated for this client?