A nurse is caring for a newborn who is 72 hr old.

Physical Examination

1100:

Neonatal Abstinence Scoring System (NAS)

Excessive high-pitched cry-2 Sleeps <2 hr 2
Hyperactive Moro reflex=2 Moderate-severe tremors disturbed=2 Increased muscle tone=2
Fever <37.2 to 38.2° C (99 to 100.8° F)=1

Excessive sucking=1 Frequent sneezing=1

Frequent yawning-1 Loose stools=2 Poor feeding=2
Respiratory rate > 60/min=1 Mottling-1
NAS score 20

The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions should the nurse anticipate? Select the 3 interventions the nurse should anticipate.

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 who has a suspected ectopic pregnancy at 8 weeks of gestation. Which of the following manifestations should the nurse expect to identify as consistent with the diagnosis?

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 a client who was admitted to the maternity unit at 38 weeks of gestation and who is experiencing polyhydramnios. The nurse should understand that this diagnosis means which of the following?

A nurse is caring for a client who is 1 hr postpartum and observes a large amount of lochia rubra and several small clots on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse take?

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 planning care for a newborn who has spinal bifida. Which of the following actions should be included in the plan of care?

A nurse is caring for a newborn immediately following birth. After assuring a patent airway, what is the priority nursing action?

A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal pad in 10 min, the client's skin color is ashen, and she states she feels weak and light headed. After applying oxygen via nonrebreather face mask at 10 L/min which of the following actions should the nurse take next?

A nurse is providing discharge teaching to a client who is 3 days postoperative following a cesarean birth. Which of the following client statements should indicate to the nurse the teaching is effective? (Select all that apply.)