51. A nurse in an antepartum clinic is caring for a client who is pregnant.

Medical History 0815:

Gravida 4 Para 3

33 weeks of gestation Allergies: Sulfa Height 165 cm (66 in)
Weight 82 kg (180 lb)

BMI 30.6

3.2 kg (7 lb) weight gain over the last 2 weeks

Select the 4 assessment findings the nurse should report to the provider.

A nurse is caring for a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

A nurse is caring for a preterm newborn who is in an incubator to maintain a neutral thermal environment. The father of the newborn asks the nurse why this is necessary. Which of the following responses should the nurse make?

1. A nurse is caring for a newborn who is 30 min old.

Nurses' Notes

1030:

Newborn placed on the birth parent's abdomen immediately following birth. Mouth and nose suctioned with bulb syringe. Dried and stimulated. Strong cry noted. Moving all extremities. Flexed tone noted. Acrocyanosis present.

1100:

Newborn is alert and active. Respirations rapid and shallow with occasional expiratory grunting, Fine crackles auscultated throughout lung fields. Small amount of green-stained vernix present in skin folds. Fingernails stained green. Molding of skull and generalized soft occipital swelling noted. Vital Signs

1030:

Axillary temperature 36.9° C (98.4° F)

Heart rate 170/min Respiratory rate 72/min

1100:

Birth weight 4,025 gm (8 lb 14 oz) (Appropriate for Gestational Age) Axillary temperature 36.7° C (97.8° F)

Heart rate 162/min Respiratory rate 80/min

After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? The condition that poses the

greatest risk to the newborn is meconium aspiration syndrome due to color of amniotic fluid.

Condition meconium aspiration syndrome meconium ileus

cold stress hypoglycemia jaundice Finding color of amniotic fluid birth weight acrocyanosis gestational age

Apgar scores

A nurse is caring for a newborn.

Complete the diagram by specifying:

1. The potential condition the newborn is most likely experiencing.
2. Two actions the nurse should take to address that condition.
3. Two parameters the nurse should monitor to assess the newborn's progress.

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?

A nurse is admitting an 8-hour old, term newborn following a cesarean birth. The nurse observes that the newborn's skin is yellow. This finding indicates the newborn is experiencing a complication related to which of the following?

A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider? 

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation.

 At which location should the nurse expect to palpate the fundus? 

A nurse in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant. The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the nurse that the client has blood in the peritoneum?

A nurse is providing teaching to the mother of a newborn born small for gestational age.
Which of the following should the nurse include as a possible cause of this condition?