A nurse is caring for a term newborn who is 48 hr old.

Physical Examination

• High-pitched cry
• Mild tremors when disturbed Increased muscle tone Sneezing six times within 1 hr Excessive sucking
• Color: Consistent with genetic background Excoriation of the chin
• Watery stools Projectile vomiting
• Hyperactive Moro reflex

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, a sign of potential improvement, or a sign of potential worsening condition.

A nurse is caring for a client who is experiencing a postpartum hemorrhage and has a new prescription for misoprostol.
Medication Administration Record

• Misoprostol 800 mcg rectally x 1 dose now
• Nifedipine 20 mg PO twice daily Ketorolac 30 mg IV every 6 hr

The nurse is assessing the client 30 min later. How should the nurse interpret the findings?

For each finding click to specify whether the finding is unrelated to the diagnosis, an indication of potential improvement, or an indication of potential worsening condition.

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 assessing a postpartum client who delivered vaginally 8 hr ago.

Select the 3 findings that require immediate follow-up.

A nurse is caring for a client who is at 33 weeks of gestation.

Medical History Gravida 2 Para 1 Preeclampsia
The nurse is assessing the client 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.

A nurse is caring for a newborn immediately following birth. For which of the following reasons should the nurse delay the instillation of antibiotic ophthalmic ointment?

A nurse is calculating the estimated date of delivery for a client who reports that the first day of her last menstrual period was August 10. Using Nägele's Rule, which of the following is the client's estimated date of delivery?

A nurse is caring for a client who is 48 hr postpartum and has a deep vein thrombosis

Vital Signs

• Blood Pressure 130/72 mm Hg
• Heart rate 90/min
• Respiratory rate 18/min
• Temperature 37" C (98.6" F)

The nurse is assessing the client 24 hr later. How should the nurse interpret the findings?

For each finding dick 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