A nurse is reviewing the medical record of a newborn who is 24 hr old. Which of the following findings requires intervention?

A nurse is caring for a client who is at 28 weeks of gestation and received no immunizations during childhood. Which of the following vaccines should the nurse plan to administer?

A nurse is caring for a client in labor who has herpes simplex virus (HSV) with active lesions. Which of the following interventions should the nurse plan to implement to prevent the transmission of HSV to the newborn?

A nurse is caring for a client who is postpartum and just delivered a newborn who weighs 4.5 kg (10 lb). Which of the following manifestations should the nurse recognize as a potential sign of hemorrhage?

A nurse is caring for a client who is in the second stage of labor and is experiencing a shoulder dystocia. The provider instructs the nurse to perform the McRoberts maneuver. Which of the following actions should the nurse take?

1. A nurse is caring for a newborn immediately following birth.

Exhibit 1

Medical History

Vacuum-assisted vaginal birth

Maternal history of positive group B streptococcus 8-hemolytic Mother received two doses of ampicillin IV bolus during labor

Exhibit 2

Vital Signs

Apgar:

Heart rate 96/min

Weak cry

Muscle tone: some flexion

Reflex: grimace

Color: acrocyanosis

Axillary temperature 36.9° C (98.5° F)

Exhibit 3

Medications

Erythromycin ophthalmic ointment once 1 to 2 hr after birth Hepatitis B vaccine 10 mcg/0.5 mL IM once within 24 hr after birth

Phytonadione 1 mg IM once 1 to 2 hr after birth

Exhibit 4

Laboratory Findings

WBC count 15,000mm (9,000 to 30,000/mm)

Hgb 19 g/dl (15 to 24 g/dL)

HCt 57% (44% to 70%)

Blood glucose 44 mg/dl (40 to 60 mg/dL)

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, an indication that the client's condition is improving, or indication that the client's condition is worsening

A nurse is assessing a client who is 1 hr postpartum. Which of the following findings should the nurse report to the provider?

A nurse is assessing a newborn who was born via a forceps-assisted birth. Which of the following findings should the nurse identify as an injury caused by the forceps?

A nurse is assessing a newborn who is 2 hr old. Which of the following findings is an indication of hypoglycemia? (Select all that apply.)

A nurse in an obstetrics clinic is caring for a client.

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Exhibit 1

Nurses' Notes

Initial visit, 1340:

29-year-old gravida 2, para 0 client presents with report of a positive home pregnancy test from 2 weeks ago. Last menstrual period was 7 weeks ago. Urine human chorionic gonadotropin (hCG) positive. Client reports vomiting several times a day over the last 2 weeks and states, "I'm a vegetarian and I don't usually eat a lot of protein, but it's still hard to keep anything down." Decreased skin turgor noted, oral mucous membranes moist. Weight 79.4 kg (175 lb).

Exhibit 2

Vital Signs

Initial visit, 1330:

• Heart rate 110/min
• Respiratory rate 18/min
• Blood pressure 104/66 mm Hg
• Temperature 36.6° C (97.9° F)
• Oxygen saturation 99% on room air
• Continuation of above exhibit

Exhibit 3

The nurse is reviewing the client's assessment findings and laboratory results.

Laboratory Results

Initial visit, 1600:

• WBC count 7,500/mm3 (5,000 to 10,000/mm3)
• Hgb 10.2 g/dL (11 to 16 g/dL)
• Hct 45% (33% to 47%)
• Platelets 360,000/mm3 (150,000 to 400,000/mm3)
• Sodium 136 mEq/L (136 to 145 mEq/L)
• Potassium 3.3 mEq/L (3.5 to 5 mEq/L)
• BUN 28 mg/dL (10 to 20 mg/dL)

Urinalysis:

• Appearance clear (clear)
• Color dark amber (pale yellow amber)
• pH 7.9 (4.6 to 8)
• Protein 4 mg/dL (0 to 8 mg/dL)
• Specific gravity 1.045 (1.005 to 1.03)
• Leukocyte esterase negative (negative)
• Nitrites none (none)

A nurse is caring for a newborn who was born at 39 weeks of gestation and is 36 hr old.

Which finding(s) from the assessment should be reported to the provider for further evaluation or intervention? Select all that apply.