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

Exhibit 1. Nurses' Notes.

0700:. Exhibit 2. 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.

Vital Signs.

0700:. Temperature 36.2° C (97.2° F). Pulse rate 80/min.

Respiratory rate 16/min.

Blood pressure 136/82 mm Hg. Pulse oximetry 999%. 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 instructions to a client who has chosen a diaphragm for birth control. Which of the following instructions should the nurse include?

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

Which of the following findings should the nurse report to the provider? Select all that apply.

A nurse is assessing a client who is in labor and has received epidural analgesia. Which of the following findings should the nurse recognize and document as an adverse effect of epidural analgesia?

A nurse is caring for a client who is in labor. Which of the following findings should prompt the nurse to reassess the client?

A nurse is planning care immediately following birth for a newborn who has a myelomeningocele that is leaking cerebrospinal fluid. Which of the following actions should the nurse include in the plan of care?

A nurse is caring for a postpartum client who recently had an indwelling urinary catheter removed. Which of the following findings indicates that the client is able to void effectively?

A nurse is caring for a client who has preeclampsia. Which of the following actions is the nurse's priority when implementing seizure precautions?

A nurse is caring for a newborn immediately following birth.

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 an indication that the client's condition is worsening.

Findings 24 hr later:

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

Exhibit 1. Nurses' Notes.

0700:. Exhibit 2. 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.

Vital Signs.

0700:. Temperature 36.2° C (97.2° F). Pulse rate 80/min.

Respiratory rate 16/min.

Blood pressure 136/82 mm Hg. Pulse oximetry 999%. 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 client who has a placenta previa. Which of the following findings should the nurse expect?