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A nurse is caring for a client who had a vaginal delivery 2 hr ago and is reporting increasing perineal pain and pressure. The nurse examines the client's perineum and sees a 4 cm (1.6 in) area of purplish discoloration with swelling. The nurse should interpret these findings as which of the following?

 

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 developing a plan of care for a client who is in the latent phase of labor.
Which of the following interventions should the nurse include in the plan to manage the client's pain?

A nurse is caring for a 28-year-old female client who is gravida 1 para 0 at 32 weeks of gestation in the prenatal unit.
Exhibit 1: History and PhysicalThe client is a 28-year-old female, gravida 1 para 0 at 32 weeks of gestation. She reports cramping and low back pain that started about 3 hours ago, with pain rated 2 on a scale of 0 to 10. She believes the contractions feel stronger than Braxton Hicks and expresses concern that it's too early for labor pains. The client mentions a small amount of urinary leakage earlier in the day, but no vaginal bleeding. She decided to come in for evaluation upon her doctor's advice.Exhibit 2: Nurses' NotesAt 0900, the client stated that she began experiencing cramping and low back pain approximately 3 hours ago, rating the pain as 2 out of 10. She described the contractions as stronger than Braxton Hicks but believed they were not labor pains. She also mentioned experiencing a small amount of urinary leakage earlier in the day, with no vaginal bleeding reported. The external fetal monitor indicated contractions every 5 minutes, lasting 30 seconds each, with moderate intensity upon palpation. Fetal heart rate was recorded at 140 beats per minute. A vaginal exam revealed a closed cervix that was 80% effaced, with clear mucus discharge observed on the exam glove.Exhibit 3: Vital SignsBlood Pressure: 120/80 mmHgHeart Rate: 80 bpmRespiratory Rate: 18 breaths/minTemperature: 98.6°F (37°C)Oxygen Saturation: 98%Exhibit 4: Physical Examination ResultsUpon physical examination, the client appeared anxious but was otherwise in stable condition. Her abdomen was soft and non-tender, with no signs of rigidity. Fetal movements were noted to be active. The client had no edema in her extremities, and her reflexes were normal. Auscultation of the lungs revealed clear breath sounds bilaterally. Cardiovascular examination showed a regular heart rhythm without any murmurs. The nurse is providing teaching about tocolytic medication. Which of the following statements should the nurse include? Select all that apply.

A nurse is caring for a client who had a vaginal delivery 2 hr ago and is reporting increasing perineal pain and pressure. The nurse examines the client's perineum and sees a 4 cm (1.6 in) area of purplish discoloration with swelling. The nurse should interpret these findings as which of the following?

A nurse is assessing a client who is at 33 weeks of gestation.

Which of the following findings should the nurse report to the provider?

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 receiving a report on four newborns born in the past 12 hr. Which of the following newborns should the nurse assess first?

A nurse is caring for a postpartum client who is breastfeeding their newborn and reports that their nipples have become sore and cracked.
Which of the following statements should the nurse make?

A nurse is providing teaching for a client who is 2 weeks postpartum and has mastitis.
Which of the following instructions should the nurse include in the teaching?

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?