A nurse is caring for a client who is in the second stage of labor. The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed.
Which condition is the client most likely experiencing?

A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding.

The client’s vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4 C (97.6° F). The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions.

What is the priority nursing action?

A nurse is caring for a client who is in the second stage of labor. The nurse observes retraction of the fetal head against the maternal perineum as the head is birthed.
Which condition is the client most likely experiencing?

A nurse is caring for a client in the second stage of labor.

The nurse observes retraction of the fetal head against the maternal perineum after the fetal head is birthed.

What potential condition could the client be experiencing, what parameters should the nurse monitor to assess the client’s progress, and what actions should the nurse take?

A nurse is leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use.
Which of the following responses should the nurse make?

A nurse is caring for a client who is 39 weeks pregnant and in active labor.

The nurse detects the fetal heart tones above the client’s umbilicus at the midline.

Which of the following positions should the nurse suspect the fetus is in?

A nurse is providing care for a patient who is at 34 weeks of gestation. The nurse is reviewing the patient’s electronic medical record to develop a plan of care. Which condition is the patient most likely experiencing, what are two actions the nurse should take to address that condition, and what are two parameters the nurse should monitor to assess the patient’s progress?

A nurse is admitting a patient with severe pre-eclampsia at 35 weeks of gestation and is reviewing the provider’s orders.
Which of the following orders requires clarification?

A nurse is preparing an in-service program about preventing medication errors when transcribing a prescription.
The nurse is using a dosage example of two tenths of a milligram.

 Which of the following examples should the nurse use to show appropriate transcription of this dosage? 

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation.
At which location should the nurse expect to palpate the fundus?

A nurse is caring for a patient who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 minutes.

The nurse suspects placenta previa.

What would be an appropriate nursing action in this situation?