Take full exam for free

A nurse is providing care to a woman who is at 36 weeks of gestation and in preterm labor with ruptured membranes.
The nurse determines that the client's oral temperature is 39.0 C (102.2 F). Besides notifying the provider, which of the following is an appropriate nursing action?

A nurse is caring for four newborns in a special care nursery.
Which of the following newborn assessment findings requires immediate intervention?

A 38-year-old multigravida returns to the clinic for a routine prenatal visit at 36 weeks gestation. Assessment findings include: blood pressure 140/90 mm Hg; pulse, 80 beats/min; respiratory rate, 16 breaths/min. The nurse suspects preeclampsia.
What additional finding would the nurse assess for?

A nurse is caring for a client whose pregnancy was complicated by polyhydramnios and is now 5 hours postpartum following a vaginal birth. The nurse should recognize that this client is at risk for which of the following postpartum complications?

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 caring for a 28-year-old female client in the fourth stage of labor after a vaginal delivery in the labor and delivery unit.
 

History and Physical: The client is a Gravida 3 Para 2 (T2P0A0L2) with chronic hypertension. She was admitted for medical induction of labor due to gestational diabetes with a Bishop score of 9 on admission. The plan was to induce labor with oxytocin.

Vital Signs:

1130:

• Blood Pressure: 144/92 mmHg
• Pulse: 99 bpm
• Respirations: 17/min
• Temperature: 100.4°F (38.0°C)
• Pulse Ox: 97%

Nurses Notes: At 1040, the client underwent a vacuum-assisted vaginal delivery of a viable female infant weighing 4215 grams. The placenta was manually extracted at 1035, appearing intact. At 1130, the fundus was boggy, midline, and at the umbilicus. Lochia rubra was heavy with small clots noted. The IV was patent and currently infusing ordered oxytocin.

Diagnostic Tests:

• Hemoglobin: 11g/dL (9.5-11 g/dL)
• Hematocrit: 33% (28-33%)
• White Blood Cell Count: 12,000/mm³ (5,600-17,000/mm³)
• Platelets: 151,000/mm³ (140,000-400,000/mm³)
• Protein Creatinine Ratio: 0.01 (less than 0.3)
• HbA1c: 8.9% (less than 5.7%)

Querry: Which of the following assessment findings require follow-up? Select All That Apply.

A client arrives at OB triage with complaints of decreased fetal movement for the past 24 hours.
The client states, "I see the high-risk clinic because I have chronic hypertension and gestational diabetes.”. The nurse applies the external fetal monitors and identifies a fetal heart rate baseline of 120 bpm, absent variability, no accelerations, and recurrent late decelerations.

What fetal heart rate category would the nurse communicate to the provider?

A nurse is assisting a teenage client with breastfeeding.
The client asks, "How will I know when to feed my baby?" The nurse educates the client on infant feeding cues. Which of the following is a newborn feeding cue?

A nurse is caring for a postpartum client who arrives at the clinic for her follow-up appointment 4 weeks after delivery.
The client is asking about birth control options. What contraception option would you recommend as being the most reliable?

A nurse is educating a client on breastfeeding positions.
Which of the following should the nurse discuss?

A nurse is caring for a newborn and assessing newborn reflexes.
To elicit the Moro (or startle) reflex, the nurse should take which of the following actions?