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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 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 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 client, at 6 weeks gestation, arrives at the OB clinic for her initial visit and requests to hear the fetal heartbeat.
What should the nurse include in the teaching regarding cardiac development?

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 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.

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 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 is caring for a client who is receiving intravenous magnesium sulfate for preeclampsia.
Which assessment finding would alert the nurse to suspect magnesium toxicity?

A nurse is caring for a newborn 4 hours after birth.
Which of the following actions should the nurse include in the plan of care to prevent jaundice?

A nurse is caring for a 28-year-old postpartum female client in the postpartum unit.

Medical History:

The client is on postpartum day 1. She is breastfeeding her newborn every 4 to 5 hours for 30 to 40 minutes each time. She reports some nipple discomfort during the feedings. The nurse assisted the client with positioning and latch and recommended the client awaken the newborn to feed every 3 hours during the day. The newborn voided twice and passed two meconium stools in the past 24 hours.

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: On postpartum day 2, the client reports breastfeeding every 3 to 4 hours and experiencing nipple discomfort during some feedings. No physical findings of nipple trauma are noted, and the breasts are soft. The client denies feelings of fullness. The newborn voided twice and passed three meconium stools in the second 24 hours of life. Discharge teaching was provided to the client regarding breastfeeding.

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.