Nurses' Notes 0800:

Newborn placed on radiate warmer. Color consistent with newborn's genetic background. Acrocyanosis present. Mild grunting, nasal flaring and intermittent retractions noted.

0830:

Grunting, nasal flaring, and sternal retractions noted. Color consistent with newborn's genetic background. Acrocyanosis present.

Select the 4 findings the nurse should report to the provider.

r.

A nurse is caring for a client who is 7 days postpartum and calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which of the following interventions should the nurse suggest?

A nurse is caring for a client who gave birth 2 hr ago. The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?

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

Medical History 1000:

39- week gestation

Emergency cesarean birth for abruptio placenta and non-reassuring fetal heart rate
Apgar 5 at 1 min 8 at 5 min

Positive pressure ventilation given for 1 min followed by free flow oxygen Select the 5 findings the nurse should report to the provider.

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 assessing a client who is 4 hr postpartum following a vaginal delivery. Which of the following findings should the nurse identify as the priority?

A nurse is caring for a newborn who has hydrocephalus. Which of the following manifestations should the nurse expect to find?

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

1. 29. A nurse is providing care at a routine visit for a client who is at 36 weeks of gestation.

   Nurses' Notes

   0900:

   Reports to clinic for routine visit. Reports a mild headache for the last several days as well as "heartburn." Denies visual disturbances. Also denies vaginal bleeding or leakage of fluid from the vagina. Reports occasional contraction and positive fetal movement. Also reports they are unable to remove rings from fingers for the last several days.
   1000:

   Reports headache is more severe and rates pain as a 5 on a 0 to 10 pain scale, Reports feeling dizzy when they got up from examination table
   Which of the following findings should the nurse report to the provider?
   
   (Select all that apply.)
   

1. A nurse is caring for a newborn who is 30 min old.

Nurses' Notes

1030:

Newborn placed on the birth parent's abdomen immediately following birth. Mouth and nose suctioned with bulb syringe. Dried and stimulated. Strong cry noted. Moving all extremities. Flexed tone noted. Acrocyanosis present.

1100:

Newborn is alert and active. Respirations rapid and shallow with occasional expiratory grunting, Fine crackles auscultated throughout lung fields. Small amount of green-stained vernix present in skin folds. Fingernails stained green. Molding of skull and generalized soft occipital swelling noted. Vital Signs

1030:

Axillary temperature 36.9° C (98.4° F)

Heart rate 170/min Respiratory rate 72/min

1100:

Birth weight 4,025 gm (8 lb 14 oz) (Appropriate for Gestational Age) Axillary temperature 36.7° C (97.8° F)

Heart rate 162/min Respiratory rate 80/min

After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? The condition that poses the

greatest risk to the newborn is meconium aspiration syndrome due to color of amniotic fluid.

Condition meconium aspiration syndrome meconium ileus

cold stress hypoglycemia jaundice Finding color of amniotic fluid birth weight acrocyanosis gestational age

Apgar scores

Nurses' Notes 0800:

Newborn placed on radiate warmer. Color consistent with newborn's genetic background. Acrocyanosis present. Mild grunting, nasal flaring and intermittent retractions noted.

0830:

Grunting, nasal flaring, and sternal retractions noted. Color consistent with newborn's genetic background. Acrocyanosis present.

Select the 4 findings the nurse should report to the provider.

r.