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A nurse is completing a health history and assessment for a client who reports they are pregnant.
Which of the following findings is a presumptive sign of pregnancy?

A nurse on an antepartum unit is caring for a 28-year-old gravida 1 para 0 female client at 32 weeks of gestation.

Exhibit 1: History and Physical The client is 32 weeks pregnant and has been experiencing cramping and low back pain for the past 3 hours. She rates her pain as 2 on a scale of 0 to 10. She describes the pain as stronger than usual Braxton Hicks contractions and mentions having a little urinary leakage earlier in the day. She denies vaginal bleeding. The client decided to come in for evaluation at her doctor's advice.
 

Exhibit 2: Nurse's Notes 0900: The client reports cramping and low back pain started 3 hours ago. She rates the pain as 2 on a scale of 0 to 10. She feels the contractions are stronger than usual Braxton Hicks contractions. She mentions urinary leakage earlier today but denies any vaginal bleeding. The external fetal monitor shows contractions occurring every 5 minutes, lasting 30 seconds, and of moderate intensity. Fetal heart rate is 140/min. A vaginal exam reveals the cervix is closed and 80% effaced. No bleeding is noted, but there is clear mucus discharge on the exam glove.

Exhibit 3:

Vital Signs Heart rate: 80/min

Blood pressure: 120/80 mmHg

Respiratory rate: 18/min

Temperature: 36.8°C (98.2°F)

Oxygen saturation: 98%Exhibit 4:

Physical Examination Results

The client's abdomen is soft, non-tender, and the fundal height corresponds to the gestational age. No signs of vaginal bleeding are observed. Clear mucus discharge is noted on the exam glove. The cervix is closed and 80% effaced. The fetal heart rate is regular at 140/min. The client appears anxious but is in no acute distress. The fetal movements are felt and reported to be normal.

Complete the following sentence by using the list of options. The nurse should identify that _______ are findings that require follow-up.

A nurse is assessing a newborn.
Which of the following findings indicates a need to check the newborn's blood glucose level for hypoglycemia?

A nurse is planning care for a newborn who was exposed to active genital herpes simplex virus (HSV) during birth.
Which of the following nursing actions should the nurse anticipate?

A nurse is caring for a 2-day-old newborn who has a bilirubin level of 14 mg/dL (1 to 12 mg/dL) and is to begin phototherapy.
Which of the following actions should the nurse take?

A nurse is caring for a group of clients who are postpartum.
Which of the following clients is at an increased risk for a fall?

A nurse is reviewing the laboratory results for a client who is at 29 weeks of gestation and has a history of anemia.
Which of the following results should the nurse identify and report as an indication of a prenatal complication?

A nurse is performing a contraction stress test (CST) on a client who is at 40 weeks of gestation.
The results of the test indicate a negative CST. Which of the following actions should the nurse take?

A nurse is admitting a client who is at 39 weeks of gestation and in active labor. The client reports being positive for group B streptococcus (GBS) when screened at 36 weeks of gestation. Which of the following actions should the nurse expect to take?

A nurse is admitting a client who is at 9 weeks of gestation and in active labor when screened at 6 weeks of gestation.
Which of the following actions should the nurse take?

A nurse is caring for a client who is 3 days postpartum in the postpartum unit.

History and Physical: A 30-year-old female client had a vaginal birth 3 days ago with prolonged rupture of membranes. Internal fetal monitoring was used during labor. The client has been experiencing fever, chills, and abdominal pain. She has a history of gestational diabetes and hypertension.

Nurses Notes: The client reports feeling weak and fatigued. She has been having difficulty breastfeeding and feels engorged. The lochia is malodorous and heavy. She complains of a headache and dizziness. The client has been crying frequently and expresses feeling overwhelmed. She also mentions that she has not been able to sleep well since delivery.

Vital Signs:

Temperature: 38.5°C (101.3°F)

Pulse: 110 bpm
Respiratory rate: 24 breaths per minute

Blood pressure: 140/90 mmHg

Oxygen saturation: 98% on room air

Physical Examination Results:

The client appears pale and diaphoretic. Her breasts are tender and engorged with signs of erythema. The abdomen is soft but tender to palpation, especially in the lower quadrants. The fundus is boggy and located above the umbilicus. Lochia is heavy and malodorous. There is mild pedal edema noted in both lower extremities.

Querry:A nurse is caring for a client who is 3 days postpartum. Which of the following actions should the nurse take? (Click on the "Exhibit" button for additional information about the client.)