The nurse is caring for a client who is 40-weeks gestation in active labor and has received epidural anesthesia.

What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia?

The nurse is reviewing a client’s chart.

Click to highlight areas of client history and physical below that increase the risk for postpartum hemorrhage.

Client was middle-aged and married.

She was in labor for 25 hours and forceps were used to assist with the delivery.

She was given an epidural for anesthesia that was effective.

The labor and delivery nurse reported that the client had a 4th degree laceration, and her pain was currently at a 4 on a 0 to 10 pain scale.

Her vital signs were stable, and she was catheterized for 500 mL of light-yellow urine just prior to delivery.

Her spouse was at the bedside for delivery.

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

A 3-year-old female patient woke up this morning feeling agitated and with a fever of 103.4° F (39.7° C). She was crying yesterday and reported back pain.

She has a history of asthma controlled by daily cetirizine and occasional albuterol.

She has had two urinary tract infections (UTIs) in the past 4 months.

Given the patient’s history and current condition, which condition is she most likely experiencing, what actions should the nurse take, and what parameters should the nurse monitor?

The client is awake and alert, interacting with parents at the bedside.
She has thin, copious mucus from her nose and mouth and a cough.
She took her bottle in 20 minutes, with no issues.
The client’s monitor alarmed, oxygen saturation is 59%. She is cyanotic.
The client was placed in a knee-to-chest position, and the rapid response team was called.
What could be the potential cause of the client’s condition?

A patient in active labor is prescribed oxytocin 12 milliunits/min intravenously (IV). The IV bag contains 5 units of oxytocin in 500 mL of lactated Ringer’s solution.

How many mL/hour should the nurse set the infusion pump to? (Enter numerical value only) .

A father observing his newborn’s admission to the nursery notices that eye ointment is applied to the infant’s eyes.

He asks the nurse about the purpose of the ointment.

What would be the correct response from the nurse regarding the purpose of the ointment?

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 17-year-old student arrives at the emergency department (ED) complaining of severe abdominal pain and cramping that has worsened since the morning.

Her mother suspects a urinary tract infection due to her daughter’s frequent and urgent urination, or possibly appendicitis.

What signs would indicate that a healthy psychosocial adaptation is taking place? Select all that apply.

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?