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A nurse is reinforcing teaching about perineal care to a client who is 2 hours postpartum and has an episiotomy and hemorrhoids. Which of the following statements by the client indicates understanding of the teaching?

A nurse is assisting with the care of a client who is in the latent phase of labor and just had an amniotomy. Which of the following findings indicates that the fetus is at risk?

A nurse is contributing to the plan of care for a client who is postpartum and has mastitis. Which of the following actions should the nurse plan to take?

A nurse is reinforcing teaching about crib safety with a group of prenatal clients. Which of the following information should the nurse include in the teaching?

A nurse is collecting data from a client during their first prenatal visit. The nurse should identify which of the following findings as a risk factor for gestational diabetes mellitus?

A nurse is reinforcing teaching with a client who is postpartum and receiving warfarin for deep-vein thrombosis. Which of the following instructions should the nurse include?

A nurse is contributing to the plan of care for a client who is in early labor and reports low-back pain during contractions. Which of the following interventions should the nurse include in the plan?

A nurse is assisting in the care of a client who is in labor and requires intermittent fetal monitoring. Which of the following actions should the nurse take?

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 in the newborn nursery is caring for an infant who has trisomy 21. When collecting data, which of the following findings should the nurse expect?

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.