The nurse is assisting a pregnant patient into bed after the patient reports a gush of fluid from the vagina. Which action will the nurse take first?

The nurse is caring for a client in labor. Which assessment finding will the nurse report to the charge nurse immediately?

The nurse is caring for a multiparous client who has been in labor for 12 hours. The client had a spontaneous vaginal delivery 2 years ago. This was an unplanned pregnancy with someone she only knew briefly. Since finding out she was pregnant, she has been alone. Her pain is now 8/10 and she is becoming fearful that something is wrong since she has been in labor so long.

Contractions assessment:

• Contractions every 3-4 minutes
• Palpating moderate in intensity
• Lasting 45-60 seconds Cervical exam: .3 cm
• 90% effaced . -2 station
• Fetus is in a cephalic presentation.

Which component of labor is keeping the client from advancing in labor?

IV calculations: (rate-mL/h and gtt/min)

• IV rate calculations will be rounded to nearest whole number.
• Adult calculations: the calculation will be rounded to the nearest tenth.

Drug Calculation safety considerations:

• Examples:
  • .5 must be answered as 0.5
  • .5.0 must be answered as 5
• To promote safety, a zero must be placed to the left of the decimal point in answers that are less than one. No zero is allowed to the right of the decimal point in answers that are whole numbers. Labeling is not necessary

Available: drug label above. Ordered: morphine sulfate 2 mg IM

How many mL of morphine will the nurse administer?

The nurse has received shift report for five clients admitted in labor. Which clients will the nurse anticipate delivering by a cesarean section? Select all that apply.

The nurse assesses the postpartum client's fundal height and tone in the first 24 hours. Which action will the nurse take to correctly assess the uterine fundus?

The nurse is caring for a client in labor. Assessment reveals that the fetus is in a vertex presentation and at -4 station. What does the nurse determine as the position of the fetal head?

The nurse is caring for a client in labor. Assessment findings: The fetal heart rate (FHR) baseline is 120 bpm The FHR begins slowing as the contraction starts, and is back to baseline at the end of the contraction There is moderate variability of the FHR Which periodic change will the nurse document in the electronic health record?

A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Which of the following of Erikson’s developmental stages should the nurse consider in the planning?

The nurse assesses a laboring client's cervix and states it is 6 cm dilated and 70% effaced.
The client asks what it means to be effaced. Which descriptions will the nurse include when responding to the client? Select all that apply.

IV calculations: (rate-mL/h and gtt/min)

IV rate calculations will be rounded to nearest whole number.

Adult calculations: the calculation will be rounded to the nearest tenth. Drug Calculation safety considerations:

Examples:

5 must be answered as 0.5

5.0 must be answered as 5

To promote safety, a zero must be placed to the left of the decimal point in answers that are less than one. No zero is allowed to the right of the decimal point in answers that are whole numbers.

Labeling is not necessary

Question

The nurse received report for the client at 1400. The client was given medication through her NG tube at 1800: Ampicillin 20 mL, Pepcid 10 mL, and Reglan 15 mL. After each medication was given, there was a 30 mL flush with water. Her Hemovac drained 320 mL. Her chest tube drained 210 mL. At 2000, she drank 240 mL of water. Her IV was infusing @ 150mL/hour when report was received. She has voided 275 mL. 325 mL and 310 mL.

What is her I&O from 1400- 2200?

(Separate the answers with a comma)