A nurse is caring for a 26-year-old female client who is in active labor in the labor and delivery unit.

The client has requested epidural anesthesia, and it has been administered to manage her pain during labor. The nurse is now monitoring her condition closely.

Exhibits

Select the 3 findings that would require immediate action from the nurse while the laboring mother is receiving epidural anesthesia.

A client with multiple sclerosis (MS) is receiving Interferon beta-1b 0.1875 mg SUBQ every other day.

The nurse reconstitutes the vial by slowly injecting 1.2 mL of diluent into the Interferon vial for a reconstituted solution of 0.25 mg/mL. How many mL should the nurse administer? (Enter numeric value only.

If rounding is required, round to the nearest hundredth.)

The nurse recognizes that findings consistent with elder mistreatment.

Temperature: 96.9 F (36.1 C) measured via internal probe via urinary catheter.

Heart rate: 128 beats/minute, sinus tachycardia (ST). Respirations: 14 breaths/minute.

Blood pressure: 90/79 mm Hg, pulse pressure less than 40 mm Hg. Oxygen saturation: 100% on 40% fraction of inspired oxygen (FiO2). IV fluid bolus given as prescribed.

The client’s surgical dressing is clean and dry.

Ecchymosis is noted on the abdomen around the dressing.

The client has a peripheral intravenous (PIV) line in the right forearm and one in the left hand.

The client also has a right subclavian central venous catheter infusing propofol and intravenous fluids.

Heart sounds are regular.

The skin is pink.

Capillary refill is 6 seconds.

Radial pulses are equal bilaterally.

Lung sounds are clear and equal bilaterally.

The client has an indwelling urinary catheter in place.

No urine is noted.

The client has no visitors at this time.

The social worker is attempting to contact family members.

The client opens her eyes to verbal stimuli and follows verbal commands.

Based on these observations, what is the most appropriate nursing action?

The nurse is managing the care for a client with hyperparathyroidism and is reviewing the client's list of prescribed and over-the-counter medications.

Which medication(s) on the client's current medication record should the nurse discuss further with the healthcare provider? Select all that apply.

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine.
Which instruction should the nurse provide to this mother?

A nurse is caring for a female client, 84 years old, in the home environment. The client was recently hospitalized for an exacerbation of heart failure (HF) and moved in with her daughter after the hospitalization. Below is the information available to the nurse for interpretation:

A client with limited tolerance for activity needs to walk in the hallway with assistance.

Which instruction(s) should the nurse give to the unlicensed assistive personnel (UAP) who is assisting with the client's care? Select all that apply.

A client who was a victim of a rape and was confirmed HIV positive six months ago arrives at the clinic for an appointment.

The client is thin, with a saddened affect and talks about frequently crying and feeling hopeless.

The client describes not wanting to see anyone or go out of the house.

Which action should the nurse take?

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

A nurse is monitoring a client receiving a blood transfusion. Which of the following actions should the nurse take first?