A nurse is administering a hepatitis B vaccine to a newborn. Which of the following actions should the nurse take?

A nurse is caring for a term newborn who is 48 hr old.

Physical Examination

• High-pitched cry
• Mild tremors when disturbed Increased muscle tone Sneezing six times within 1 hr Excessive sucking
• Color: Consistent with genetic background Excoriation of the chin
• Watery stools Projectile vomiting
• Hyperactive Moro reflex

The nurse is assessing the newborn 24 hr later. How should the nurse interpret the findings?

For each finding, click to specify whether the finding is unrelated to the diagnosis, a sign of potential improvement, or a sign of potential worsening condition.

A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?

A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a new prescription for misoprostol.
Medication Administration Record

• Misoprostol 800 mcg rectally x 1 dose now
• Nifedipine 20 mg PO twice daily Ketorolac 30 mg IV every 6 hr

The nurse is assessing the client 30 min later. How should the nurse interpret the findings?

For each finding click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.

A nurse is caring for a client who reports spontaneous rupture of membranes. The nurse observes fetal bradycardia on the FHR tracing and notices that the umbilical cord is protruding. After calling for assistance and notifying the provider, which of the following actions should the nurse take next?