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A nurse is reinforcing teaching with a mother who is bottle feeding her newborn with formula. Which of the following statements should the nurse include in the teaching?

A nurse is caring for a client who is at 39 weeks of gestation and is in active labor.

The nurse notes maternal exposure to rubella during pregnancy. After delivery, the nurse should monitor the newborn for which of the following conditions?

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 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 caring for a client who is postpartum and has an episiotomy. Which of the following actions should the nurse take?

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

A nurse on the postpartum unit is caring for a client who delivered vaginally 3 hr ago. Which of the following manifestations is a possible indication of postpartum hemorrhage?

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 had a vaginal delivery 1 day ago. The nurse determines that the client's fundus is firm, located 2 fingerbreadths above the umbilicus, and deviated to the left. Which of the following actions should the nurse take first?

A nurse in a prenatal clinic is collecting data from a client who is at 26 weeks of gestation. Which of the following findings reported by the client should the nurse report to the provider?

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?