A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina.

Which of the following actions should the nurse perform first?

A nurse is caring for a newborn who is 56 hours old.
Vital Signs: At 07:00: Awake, alert, and crying.
The color is pink with acrocyanosis.
The respiratory rate is 70/min with no retractions, grunting, or nasal flaring noted.
Jitteriness is noted in the hands.
At 07:20: Attempted to feed the newborn.
Poor feeding and poor suck were noted.
Loose stool was observed in the diaper, which was then changed.
Which of the following assessment findings is consistent with neonatal abstinence syndrome (NAS)?

A nurse is caring for a newborn who is 4 hours old. After reviewing the information in the newborn’s medical record, the nurse should recognize that the newborn is at risk for developing which of the following complications?

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

A nurse is caring for a client who is 36 hours postpartum.

The nurse’s notes indicate the following: Breasts are soft, warm, and tender to touch. The client denies any nipple or breast discomfort.

The fundus is boggy, located 1 cm above the umbilicus and deviated to the right. The fundus becomes firm with massage.

The client reports abdominal cramping and rates the pain as 8 on a scale of 0 to 10. The perineal pad shows a moderate amount of lochia rubra.

The client has been given an analgesic.

After reviewing the information in the client’s medical record, which of the following complications poses the greatest risk for the client?

A nurse is caring for a newborn immediately after birth. Once a patent airway has been ensured, what should be the nurse’s priority action?

A nurse is caring for a client during the first trimester of pregnancy.
After reviewing the client’s blood work, the nurse notices she does not have immunity to rubella. When should the nurse understand is the recommended time for rubella immunization?

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client’s bladder is distended?

A nurse is caring for a patient who is at 22 weeks of gestation and has been unable to control her gestational diabetes mellitus with diet and exercise. Which of the following medications should the nurse anticipate the provider will prescribe for the patient?

A nurse in the emergency department is caring for a client who comes to the emergency department reporting severe abdominal pain in the left lower quadrant.

The provider suspects a ruptured ectopic pregnancy. Which of the following signs indicates to the nurse that the client has blood in the peritoneum?