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

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

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 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 assisting with the care of a 30-year-old female client who is scheduled to receive a dose of dinoprostone in the maternal newborn unit.

Exhibit 1: Vital Signs

• Heart rate: 88/min
• Temperature: 37.1°C (98.8°F)
• Respiratory rate: 16/min
• Blood pressure: 122/78 mm Hg

Exhibit 2: Provider Prescriptions

• Levothyroxine 100 mcg PO once daily in PM
• Acetaminophen 325 mg PO every 6 hr PRN
• Dinoprostone 10 mg intravaginally x one dose now
• Terbutaline 2.5 mcg/min intravenous per provider's instructions

Exhibit 3: Laboratory Results

• WBC count: 9,500/mm³ (Normal: 5,000 to 15,000/mm³)
• Hgb: 10.5 mg/dL (Normal: greater than 11 mg/dL)
• Hct: 31% (Normal: greater than 33%)
• Platelets: 225,000/mm³ (Normal: 150,000 to 400,000/mm³)
• Blood Type/Rh: O+

Exhibit 4: Assessment

The fetal heart rate is 140/min with moderate variability, and mild uterine irritability is noted. The abdomen is soft and nontender upon palpation. Cervical examination reveals dilation of 1 cm, thickness, and no presenting part palpable. An ultrasound shows a footling breech presentation. There are clusters of lesions noted on the vaginal introitus and labia majora.

Exhibit 5: History and Physical

The client is gravida 2 para 1, with a previous vaginal delivery. She has a history of hypothyroidism and Herpes simplex virus type 2. She is currently undergoing labor induction at 39 weeks and 3 days of gestation.

Querry

For which of the following findings should the nurse anticipate a provider's prescription to withhold the dinoprostone? Select all that apply.

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 with a client who tested positive for group B streptococcus β-hemolytic (GBS) during a prior pregnancy and is at 30 weeks of gestation. Which of the following statements should the nurse make?

A nurse in a provider's office is reviewing the medical record of a client who is requesting a diaphragm. Which of the following findings in the client's history should the nurse identify as a contraindication for this type of contraception?

A nurse is reinforcing teaching with a client who is at 18 weeks of gestation and requires an increased intake of iron. Which of the following foods should the nurse recommend as the best source of iron?

A nurse is reinforcing teaching about outpatient resources for a client who is recovering from a molar pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

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?