A nurse is caring for a newborn 8 hours of age

exhibits

Which of the following assessment findings require follow-up by the nurse?

Click to highlight the statements in the assessment findings that require follow-up by the nurse.

Axillary temperature 36.1°C (97°F)

Heart rate 160/min

Respiratory rate 78/min

Newborn is sleeping in their birth parent's arms. Awakens with stimulation. Yellow discoloration noted of sclera and oral mucosal Lung sounds clear bilaterally. Nasal flaring present. Fontanel level and soft with large ecchymotic caput succedaneum noted. Blood-tinged mucus noted at the vaginal opening. Has voided and stooled one time since birth. Uric acid crystals observed in the urine. Breastfed x 1 in the past 6 hr for 10 min

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 an adolescent client who has pelvic inflammatory disease as a consequence of a sexually transmitted infection, and will need intravenous antibiotic therapy. The client tells the nurse, "My parents think I am a virgin. I don't think I can tell them I have this kind of an infection." Which of the following responses should the nurse make?

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

A nurse is caring for a client who is pregnant.

Medical History 1100:

Gravida 4 Para 3

32 weeks of gestation BMI 32
History of two newborns weighing over 4.5 kg (10 lb) Family history of type one diabetes mellitus (maternal) Fetal heart tones 140/min via doppler
Which of the following provider prescriptions should the nurse plan to implement? Select the 3 actions the nurse should plan to take.

A nurse is preparing to assess a newborn who is postmature. Which of the following findings should the nurse expect? (Select all that apply.)

The nurse continues caring for the client:
The client is a 26-year-old female who was in a car accident 6 months s ago that killed her mother, husband, and 2-year-old son. She and her father were the only survivors of the crash. She is seeking care for depression.
Click to indicate whether findings at the next follow-up appointment indicate that the treatment was effective or ineffective. Each row must have one response selected.

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

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. Which of the following times should the nurse understand is recommended for rubella immunization?

A nurse is caring for a client who is receiving opioid epidural analgesia during labor. Which of the following findings is the nurse's priority?

A nurse in a prenatal clinic is teaching a client who is in her second trimester and has a new diagnosis of gestational diabetes. Which of the following statements by the client indicates a need for further teaching?