Patient Data

Exhibits

The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart.

For each body system, click to specify the assessment findings that indicates hypoxia. At least one finding could be indicated for each system.

Body System	Assessment Finding
Neurological	Restless Awake and alert Anxious
Respiratory	Respiratory rate 28 breaths/minute Oxygen Saturation 90% on room air Productive cough
Cardiovascular	Heart rate 101 beats/minute Capillary refill 4 seconds Blood pressure 145/89 mm Hg

Patient Data

The nurse is reviewing nurses' notes to determine if there are any variations. Click to highlight the findings that would indicate the client has developed a complication related to pregnancy.

The client is a 32-year-old multigravida at 28 weeks' gestation, who presents to the obstetrician's office for a routine prenatal visit. Obstetrical history reveals she has given birth three times; once at 35 weeks (twins), once at 38 weeks (singleton) and once at 41 weeks (singleton). All of these children are alive and well. She had one spontaneous abortion at 10 weeks' gestation. Her fourth child weighed 9 pounds (4.08

Kg) at 41 weeks gestation.

Client is at 28 weeks. She has been receiving prenatal care since 8 weeks' gestation. Her fasting 1-hour glucose screening level, which was done 1 week prior, is 164 mg/dL (9.1 mmol/L). Her 3-hour oral glucose tolerance test results reveal a fasting blood sugar of 168 (9.3 mmol/L) and a two-hour postprandial of 220 mg/dL (12.2 mmol/L).

Patient Data

Review H and P, nurse's note, flow sheet, and prescriptions.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Patient Data

Click to highlight the notes that demonstrate a positive outcome.

The client is admitted to the hospital after her membranes rupture at 38 weeks gestation. A vaginal examination is done. The nurse determines that the client is 3 cm dilated, 40% effaced, and the fetal head is at -1 station. The external monitor snows that contractions are occurring every 4 minutes and lasting 70 seconds, and the nurse palpates the quality as strong. Her fasting blood glucose (FSBG) is 86 (4.8 mmol/L).

The client is transferred to the labor- delivery-recovery (LDR) suite. The client dilates quickly to 10 cm and feels a strong urge to push. The fetal heart rate is reassuring with a baseline of 145 and moderate variability. The nurse briefly reviews pushing techniques with her and her husband and notifies the obstetrician of the client's progress. After three cycles of open-glottis pushing, the baby's head is crowning. The head is born easily over an intact perineum. The infant weighs 9 lbs. 9 oz (4.34 kgs) and has an Apgar of 7 at 1 minute, then 9 at 5 minutes.