Take full exam for free

Which of the following physical findings would lead the nurse to suspect that a client who has pre-eclampsia with severe features has developed HELLP syndrome? Select all that apply.

While you are taking Monique's vital signs and performing a postpartum assessment 4 hours after delivery, she tells you she is feeling lightheaded. She has a history of chronic hypertension and obesity.

Her vital signs are blood pressure 85/57 mm Hg, pulse 132, respirations 28, oxygen saturation 94%. Her uterus is boggy at midline, 1 cm above the umbilicus.
What would be your next steps and anticipated orders?

A nurse makes the following observations when admitting a full-term, breastfeeding baby into the neonatal nursery: 9 lb 2 oz (4,139 grams), 21 inches long, TPR 96.6°F (35.9°C), 158, 62, jittery, pink body with bluish hands and feet, crying.
Which of the following nursing actions is of highest importance?

While you are taking Monique's vital signs and performing a postpartum assessment 4 hours after delivery, she tells you she is feeling lightheaded.She has a history of chronic hypertension and obesity.

Her vital signs are blood pressure 85/57 mm Hg, pulse 132, respirations 28, oxygen saturation 94%. Her uterus is boggy at midline, 1 cm above the umbilicus.
What would be your next steps and anticipated orders?

The nurse is providing care to a postpartum patient after an emergency cesarean due to eclampsia. The patient received spinal anesthesia before delivery. Magnesium sulfate is infusing 2 g/hr in 100 mL of IV fluid.
Which assessment finding will cause the nurse to administer calcium gluconate to the patient via IV push?

The nurse is assessing a patient who is a G5P5005 and delivered vaginally four hours ago. The patient's labor history includes a 16-hour oxytocin induction for a macrosomic infant.

Assessment findings include a firm uterus and a completely saturated peri pad with the presence of blood clots.
What does the nurse identify as the most likely cause for the increased bleeding?

The nurse in a prenatal unit is providing care for a patient who experienced preterm premature rupture of the membranes (PPROM) at 32 weeks' gestation.
Which assessment does the nurse consider unnecessary?

The nurse is assisting the primary care provider (PCP) with a vacuum-assisted delivery because of a prolonged second stage of labor.
The nurse will inform the PCP when which guideline of the procedure is met?

A breastfeeding mother calls the obstetrician's office with a complaint of pain in one breast. Upon inspection, a diagnosis of mastitis is made.
Which of the following nursing interventions is appropriate?

A patient who is pregnant expresses a desire to attempt a vaginal delivery after a cesarean birth 2 years before.
The primary care provider (PCP) initiates trial of labor after cesarean (TOLAC) and vaginal birth after cesarean (VBAC) screening.

A client at 37 weeks' gestation has been advised that she is positive for group B streptococcus (GBS). Which of the following comments by the nurse is appropriate at this time?