A client at 38-weeks gestation reports experiencing severe abdominal pain.
Upon palpation, the nurse notes that the abdomen is rigid.
How should the nurse document the findings?

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

A 3-year-old male was brought into the emergency room this morning with a sudden onset of “fast and noisy breathing”. According to his parents, he had sneezing and a runny nose last week but seemed to have recovered.
The child lives with 2 older, school-age siblings, his parents, and 3 dogs.
He was born at 37 weeks’ gestation.
The parents deny smoking, but his grandmother cares for him in the afternoons and smokes outside when she is at the house.
He has no significant medical history.
He has received all vaccines except for those due at 3 years.
Upon exam, the child is… Which two items must the nurse ensure are available before attempting to place the intravenous line?

The nurse is caring for a client who is 40-weeks gestation in active labor and has received epidural anesthesia.

What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia?

A patient was received one hour after delivering a 9 lb 1 oz (4.1 kg) female baby.

Her vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.

She was assisted to the bathroom where she voided 150 mL of clear yellow urine.

Lochia rubra is moderate with small clots, no foul odor noted.

The fundus is firm at the umbilicus.

The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis.

There is no pain, redness, or swelling in the calves.

A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag.

The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.

During the second stage of labor, the fetal head has just been born and the nurse observes the immediate retraction of the head against the perineum.
What action should the nurse anticipate performing to assist the healthcare provider?

The nurse is reviewing the patient’s condition and vital signs following the placement of a 5% dextrose intravenous line.
Which medications should the nurse anticipate the healthcare provider will order? Select all that apply.

What other symptoms is the nurse likely to note in a child diagnosed with epiglottitis?

A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes.
What action should the nurse take?

The MMR vaccine (measles, mumps, and rubella) is given subcutaneously at a dose of 0.5 mL if the patient is not immune to rubella.
How should the risk of Venous Thromboembolism (VTE) and Postpartum Hemorrhage (PPH) be evaluated?

The nurse is reviewing a client’s chart.

Click to highlight areas of client history and physical below that increase the risk for postpartum hemorrhage.

Client was middle-aged and married.

She was in labor for 25 hours and forceps were used to assist with the delivery.

She was given an epidural for anesthesia that was effective.

The labor and delivery nurse reported that the client had a 4th degree laceration, and her pain was currently at a 4 on a 0 to 10 pain scale.

Her vital signs were stable, and she was catheterized for 500 mL of light-yellow urine just prior to delivery.

Her spouse was at the bedside for delivery.