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A nurse is collecting data from a client who is 18 hr postpartum. Which of the following findings require the nurse to intervene?

Which of the following symptoms should the nurse recognize as a manifestation of neonatal abstinence syndrome?

A nurse is reinforcing teaching about breastfeeding with the mother of a newborn. Which of the following instructions should the nurse include?

A nurse is reinforcing discharge teaching about breastfeeding with a client. Which of the following statements by the client indicates an understanding of the teaching?

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 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 reinforcing discharge teaching about car seat safety with the guardian of a newborn. Which of the following information should the nurse include in the teaching?

A nurse is reinforcing teaching with a client who is breastfeeding and reports nipple soreness. Which of the following recommendations 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 is caring for a client who is at 9 weeks of gestation and reports nausea in the morning that continues until midafternoon. Which of the following actions should the nurse encourage the client to take?

A nurse is assisting with the care of a 30-year-old female client who is scheduled to receive a dose of dinoprostone in the maternal newborn unit.

Exhibit 1: Vital Signs

• Heart rate: 88/min
• Temperature: 37.1°C (98.8°F)
• Respiratory rate: 16/min
• Blood pressure: 122/78 mm Hg

Exhibit 2: Provider Prescriptions

• Levothyroxine 100 mcg PO once daily in PM
• Acetaminophen 325 mg PO every 6 hr PRN
• Dinoprostone 10 mg intravaginally x one dose now
• Terbutaline 2.5 mcg/min intravenous per provider's instructions

Exhibit 3: Laboratory Results

• WBC count: 9,500/mm³ (Normal: 5,000 to 15,000/mm³)
• Hgb: 10.5 mg/dL (Normal: greater than 11 mg/dL)
• Hct: 31% (Normal: greater than 33%)
• Platelets: 225,000/mm³ (Normal: 150,000 to 400,000/mm³)
• Blood Type/Rh: O+

Exhibit 4: Assessment

The fetal heart rate is 140/min with moderate variability, and mild uterine irritability is noted. The abdomen is soft and nontender upon palpation. Cervical examination reveals dilation of 1 cm, thickness, and no presenting part palpable. An ultrasound shows a footling breech presentation. There are clusters of lesions noted on the vaginal introitus and labia majora.

Exhibit 5: History and Physical

The client is gravida 2 para 1, with a previous vaginal delivery. She has a history of hypothyroidism and Herpes simplex virus type 2. She is currently undergoing labor induction at 39 weeks and 3 days of gestation.

Querry

For which of the following findings should the nurse anticipate a provider's prescription to withhold the dinoprostone? Select all that apply.