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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 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 teaching a prenatal class to a group of parents and is discussing facilitation of sibling acceptance of the newborn.
Which of the following instructions should the nurse include in the teaching?

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 assessing a client who has placenta previa and is receiving fetal monitoring.
Which of the following clinical findings should the nurse expect?

A nurse is teaching a client about iron supplementation during pregnancy.
Which of the following client statements indicates an understanding of the teaching?

A nurse is planning to obtain a blood specimen from a newborn via a heel stick.
Which of the following actions should the nurse take?

A charge nurse is providing teaching to a newly licensed nurse who is caring for a client who has postpartum hemorrhagic shock.
Which of the following statements should the charge nurse make?

A nurse is assessing a client who is in active labor. The client reports back labor pains.
Which of the following nonpharmacological interventions should the nurse provide to manage the client's pain?

A nurse is reviewing the results of a nonstress test for a client who is at 37 weeks of gestation.
Which of the following findings indicates a reactive nonstress test?

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?