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 caring for a newborn who has jaundice and a new prescription for phototherapy. Which of the following actions should the nurse take?

A nurse is assessing a newborn who was born via a forceps-assisted birth. Which of the following findings should the nurse identify as an injury caused by the forceps?

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 planning care for a client who is 12 hr postpartum and has a third-degree perineal laceration. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client who is in labor. The nurse observes late decelerations of the fetal heart rate on the external fetal monitor. After placing the client in a side-lying position, which of the following actions should the nurse 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?

A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.

Which finding(s) from the assessment should be reported to the provider for further evaluation or intervention? Select all that apply.

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 is caring for a client who is experiencing infertility and is requesting in vitro fertilization. Which of the following information should the nurse provide to 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.