1. A nurse is assessing a postpartum client who delivered vaginally 8 hr ago.

Exhibit 1

Nurses' Notes

0700:

Breasts soft, nipples intact. Uterus palpated firm, midline, and at level of umbilicus. Moderate amount of lochia rubra. Episiotomy site well approximated with mild edema and ecchymosis. Client reports pain as 2 on a scale of 0 to 10. Able to void spontaneously; no bladder distention. Deep tendon reflexes 1+. Peripheral edema 2+ in bilateral lower extremities.

1100:

Breasts soft, nipples intact. Uterus palpated soft with lateral deviation and 1 cm above the umbilicus. Large amount of lochia rubra. Episiotomy site well approximated with mild edema and ecchymosis. Client reports pain as 3 on a scale of 0 to 10. Deep tendon reflexes 1+ Peripheral edema 2+ in bilateral lower extremities.

Exhibit 2

0700:

Temperature 36.2" C (97.2" F) Pulse rate 80/min

Respiratory rate 16/min

Blood pressure 136/82 mm Hg

Pulse oximetry 99%

1100:

Temperature 37.2° C (99.0° F)

Pulse rate 85/min

Respiratory rate 18/min

Blood pressure 136/86 mm Hg

Pulse oximetry 100%

Select the 3 findings that require immediate follow-up.

A nurse is providing teaching to a postpartum client who has a prescription for a rubella immunization. Which of the following client statements Indicates understanding of the teaching?

A nurse is preparing to perform a heel stick on a newborn who has a prescription for a total serum bilirubin. Which of the following actions should the nurse take?

A nurse in an obstetrics clinic is caring for a client.

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Exhibit 1

Nurses' Notes

Initial visit, 1340:

29-year-old gravida 2, para 0 client presents with report of a positive home pregnancy test from 2 weeks ago. Last menstrual period was 7 weeks ago. Urine human chorionic gonadotropin (hCG) positive. Client reports vomiting several times a day over the last 2 weeks and states, "I'm a vegetarian and I don't usually eat a lot of protein, but it's still hard to keep anything down." Decreased skin turgor noted, oral mucous membranes moist. Weight 79.4 kg (175 lb).

Exhibit 2

Vital Signs

Initial visit, 1330:

• Heart rate 110/min
• Respiratory rate 18/min
• Blood pressure 104/66 mm Hg
• Temperature 36.6° C (97.9° F)
• Oxygen saturation 99% on room air
• Continuation of above exhibit

Exhibit 3

The nurse is reviewing the client's assessment findings and laboratory results.

Laboratory Results

Initial visit, 1600:

• WBC count 7,500/mm3 (5,000 to 10,000/mm3)
• Hgb 10.2 g/dL (11 to 16 g/dL)
• Hct 45% (33% to 47%)
• Platelets 360,000/mm3 (150,000 to 400,000/mm3)
• Sodium 136 mEq/L (136 to 145 mEq/L)
• Potassium 3.3 mEq/L (3.5 to 5 mEq/L)
• BUN 28 mg/dL (10 to 20 mg/dL)

Urinalysis:

• Appearance clear (clear)
• Color dark amber (pale yellow amber)
• pH 7.9 (4.6 to 8)
• Protein 4 mg/dL (0 to 8 mg/dL)
• Specific gravity 1.045 (1.005 to 1.03)
• Leukocyte esterase negative (negative)
• Nitrites none (none)

A nurse is assessing a client who is 6 hr postpartum and is saturating perineal pads every 10 to 15 min. Which of the following actions should the nurse take first?

1. A nurse is caring for a newborn immediately following birth.

Exhibit 1

Medical History

Vacuum-assisted vaginal birth

Maternal history of positive group B streptococcus 8-hemolytic Mother received two doses of ampicillin IV bolus during labor

Exhibit 2

Vital Signs

Apgar:

Heart rate 96/min

Weak cry

Muscle tone: some flexion

Reflex: grimace

Color: acrocyanosis

Axillary temperature 36.9° C (98.5° F)

Exhibit 3

Medications

Erythromycin ophthalmic ointment once 1 to 2 hr after birth Hepatitis B vaccine 10 mcg/0.5 mL IM once within 24 hr after birth

Phytonadione 1 mg IM once 1 to 2 hr after birth

Exhibit 4

Laboratory Findings

WBC count 15,000mm (9,000 to 30,000/mm)

Hgb 19 g/dl (15 to 24 g/dL)

HCt 57% (44% to 70%)

Blood glucose 44 mg/dl (40 to 60 mg/dL)

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, an indication that the client's condition is improving, or indication that the client's condition is worsening

A nurse is assessing the newborn of a client who reports methadone use during pregnancy. The nurse should expect the newborn to exhibit which of the following manifestations?

A nurse is assessing a client who is at 28 weeks of gestation and has a Clostridium difficile infection. The nurse should initiate which of the following types of isolation precautions for the client?

A nurse is caring for the client at the next prenatal visit.

After reviewing the assessment findings, which of the following complications is the client at an Increased risk for developing?

Select the 3 complications the client is at an increased risk for developing.

A nurse is planning care for a client who is 1 hr postpartum and has preeclampsia without severe features. Which of the following actions should the nurse plan to take?

A nurse is assessing the results of a nonstress test for an antepartal client at 35 weeks of gestation. Which of the following findings should indicate to the nurse the need for further diagnostic testing?