A patient was received one hour after delivering a 9 lb 1 oz (4.1 kg) female baby.

Her vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.

She was assisted to the bathroom where she voided 150 mL of clear yellow urine.

Lochia rubra is moderate with small clots, no foul odor noted.

The fundus is firm at the umbilicus.

The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis.

There is no pain, redness, or swelling in the calves.

A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag.

The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.

A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes.
What action should the nurse take?

The nurse receives 2 newborns within the first minutes after a vaginal delivery and intervenes to establish adequate respirations.
What is the priority issue that the nurse should address to ensure the newborn’s survival?

During the second stage of labor, the fetal head has just been born and the nurse observes the immediate retraction of the head against the perineum.
What action should the nurse anticipate performing to assist the healthcare provider?

A woman is in the second stage of labor where the fetal head has just been born and the nurse observes the immediate retraction of the head against the perineum.
What action should the nurse expect to perform to assist the healthcare provider?

An adolescent client who has successfully managed hemophilia for the past 10 years is evaluated by the nurse.
Which behavior best evidences the client’s adjustment to the disorder as an adolescent?

A client’s maternal serum alpha-fetoprotein level is elevated at 17 weeks.
What condition should the nurse identify as the likely cause of this increase?

A 3-year-old male was brought into the emergency room this morning with a sudden onset of “fast and noisy breathing”. What other symptoms is the nurse likely to note in a child diagnosed with epiglottitis?

The nurse is educating parents on how to prevent recurrent otitis media in their infant.
What advice should the nurse give?

A client at 28-weeks gestation whose hemoglobin level is 10.7 g/dL (107 g/L) and hematocrit is 32.3% (0.323 volume fraction), tells the nurse that she eats plenty of green vegetables.
When the client asks the nurse how the pregnancy might affect the laboratory findings, which information should the nurse provide?

The nurse finds that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis.
What action should the nurse take?