The nurse is caring for a laboring client with early decelerations and a fetal heart rate baseline of 130 with moderate variability. What will the nurse do for this client?

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?

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?

The nurse is admitting a pregnant client into the labor and delivery unit. Which findings indicate the client is in the latent phase of the first stage of labor? Select all that apply.

The nurse is caring for a client at 42 weeks' gestation arriving for an induction of labor. The provider is planning to use dinoprostone (Cervidil) vaginal insert for cervical ripening. What is the nurse's priority prior to insertion?

The nurse is caring for a client on the postpartum unit who had a vaginal delivery with epidural anesthesia 2 hours ago. 1. The client presses the call light and tells the nurse she needs to use the bathroom 2. The nurse arrives in the client's room 5 minutes later 3.

The client is getting out of bed alone What is the best response by the nurse?

The nurse takes a phone call from a client at two weeks postpartum. The client states, "My left breast hurts." What other question will the nurse ask her to determine if it is mastitis?

The nurse is caring for a laboring client. The nurse observes that there are variable decelerations. What is the nurse's priority action?

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 is assessing four clients on the postpartum unit. Each client's uterine assessment is below. 1. The client is three days postpartum and her fundus is 3 cm below the umbilicus 2. The client is two days postpartum and her fundus is 2 cm above the umbilicus 3. The client is one day postpartum and her fundus is 1 cm below the umbilicus 4. The client delivered 8 hours ago and her fundus is at the umbilicus

Which client is experiencing uterine subinvolution?

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)