ATI Online Assessment Qs

A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic tests? Biophysical profile Amniocentesis Cordocentesis Kleihauer-Betke test

Biophysical profile A positive contraction stress test indicates that further evaluation of the fetus is necessary. A biophysical profile will provide further evaluation with a real-time ultrasound.

A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopold maneuvers. Which of the following images indicates the first step of Leopold maneuvers? see image

Evidence-based practice indicates the nurse should perform this step first when performing Leopold maneuvers. During this step, the nurse palpates the client's abdomen with the palms to determine which fetal part is in the uterine fundus. This step also identifies the lie (transverse or longitudinal) and presentation (cephalic or breech) of the fetus. number3

A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication? Hypertension Hypothermia Constipation Muscle weakness

Hypertension The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension.

A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider? Late decelerations Moderate variability of the FHR Cessation of uterine dilation Prolonged active phase of labor

Late decelerations Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider.

A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old child in accepting the new family member? Allow the sibling to hold the newborn during a bath. Make sure the sibling kisses the newborn each night. Obtain a gift from the newborn to present to the sibling. Switch the sibling's room with the nursery.

Obtain a gift from the newborn to present to the sibling. Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age sibling's acceptance of a new family member. This ensures that the sibling does not feel left out and that they understand their role in the family.

A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect? Bruising over the buttocks Hard nodules on the roof of the mouth Petechiae over the head Bilateral periauricular papillomas

Petechiae over the head Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising and petechiae over the face, head, and neck.

A nurse is reviewing the provider's prescription in the adolescent's medical chart. Exhibit 1 History and Physical Adolescent is sexually active with two current partners. IUD in place Reports not using condoms during sexual activity. History of type 1 diabetes mellitus Exhibit 2 Nurses' Notes 1300:Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on 0 to 10 pain scale and describes pain as constant and dull. Reports nausea and vomiting over past 24 hours.Reports painful urination and pain during sexual intercourse with minimal vaginal itching.Tenderness with palpation to lower abdomen, guarding abdomen observed. Greenish vaginal discharge observed.Reports last menstrual period was 3 weeks ago as normal period that lasted 4 days Exhibit 3 Vital Signs 1300: Blood pressure 118/72 mm Hg Heart rate 100/min Respiratory rate 20/min Temperature 38.3° C (101° F) Exhibit 4 Provider Prescriptions 1300:Standing prescriptions for clients who present with abdominal pain: Obtain laboratory tests: UrinalysisCervical culture C-reactive protein Beta hCG 1400:Ceftriaxone 250 mg IM stat Discharge prescriptions: Doxycycline 100 mg tab PO twice daily for 7 days Metronidazole 500 mg PO twice daily for 14 days Ondansetron 8 mg sublingual tab every 8 hr PRN nausea Ibuprofen 400 mg tab PO every 4 to 6 hr PRN pain Exhibit 5 Diagnostic Results 1335: Urinalysis: Appearance clear (clear) Color amber yellow (amber yellow) pH 6.5 (4.6 to 8.0) Leukocyte esterase negative (negative) WBC count 0 (0 to 4) Nitrites none (none) Cervical culture pending C-reactive protein 12.2 mg/dL (<1.0 mg/dL) Beta hCG 3 IU/L negative (<5 IU/L) Exhibit 6 Progress Report 1410: 16-year-old sexually active adolescent who reports having unprotected sex. Reports cramping pain in lower abdomen, tender with palpation. Reports painful urination and pain during sex. Vaginal and pelvic exams reveal greenish, thick vaginal discharge, swollen and red labia. Treat adolescent for gonorrhea and mild PID: ceftriaxone to be given in clinic. Discharge instructions and prescriptions include doxycycline, metronidazole, ondansetron, ibuprofen. Instruct to complete all medications. Refrain from sex until treatment is complete. All partners should be notified and be treated for infection. Counsel regarding condom use. Discuss complications of reinfection and when to see provider. Return to office in 1 month. The nurse is reviewing the provider's prescriptions in the adolescent's medical chart. Complete the following sentence by using the list of options. The nurse should first implement administering doxycycline scheduling follow-up appointments providing education on medications and educating on condom use administering metronidazole administering ceftriaxone

providing education on medications administering ceftriaxone Dropdown 1 Providing education on medications is correct. The nurse should first educate the adolescent regarding medications because clients have the right to know the purpose and potential adverse reactions of all prescribed medications before receiving them. An understanding of the prescribed medications will increase the likelihood that the adolescent will adhere to the prescribed therapy. Dropdown 2 Administering ceftriaxone is correct. Ceftriaxone is designated as a NOW prescription, which means it should be given within 90 min of the provider writing the prescription. The nurse should administer ceftriaxone after educating the adolescent about the purpose and potential adverse reactions of the medication.

A nurse in a clinic is caring for a 16-year-old adolescent. Exhibit 1 History and Physical ​Adolescent is sexually active with two current partners.IUD in placeReports not using condoms during sexual activity.History of type 1 diabetes mellitus Exhibit 2 Nurses' Notes 1300:Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on 0 to 10 pain scale and describes pain as constant and dull. Reports nausea and vomiting over past 24 hours.Reports painful urination and pain during sexual intercourse with minimal vaginal itching.Tenderness with palpation to lower abdomen, guarding abdomen observed. Greenish vaginal discharge observed. Reports last menstrual period was 3 weeks ago as normal period lasted 4 days. Exhibit 3 Vital Signs 1300:Blood pressure 118/72 mm HgHeart rate 100/minRespiratory rate 20/minTemperature 38.3° C (101° F) Exhibit 4 Provider Prescriptions 1300:Standing prescriptions for clients who present with abdominal pain:Obtain laboratory tests:UrinalysisCervical cultureC-reactive proteinBeta hCG Which of the following conditions should the nurse identify as being consistent with the adolescent's assessment findings? For each finding, click to specify if the assessment findings are consistent with trichomoniasis, gonorrhea, or candidiasis. Each finding may support more than one disease process. See image

Abdominal pain is consistent with gonorrhea. Gonorrhea can present with reports of acute or chronic lower abdominal pain. Greenish discharge is consistent with trichomoniasis and gonorrhea. Green-yellow discharge can occur in both trichomoniasis and gonorrhea. Candidiasis causes thick, white, lumpy discharge. Diabetes is consistent with candidiasis. Diabetes is a predisposing factor for yeast infections because high glucose levels provide an environment with enough glucose to allow the growth of yeast. Pain on urination is consistent with trichomoniasis, gonorrhea, and candidiasis. Dysuria is a manifestation of trichomoniasis, gonorrhea, and candidiasis and can be the result of urine flowing over an irritated and inflamed vulva and surrounding skin. Absence of condom use is consistent with trichomoniasis and gonorrhea. Sexual activity without the use of a condom can result in the transmission of STIs. Candidiasis is a vaginal infection that is not sexually transmitted.

A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? Abruptio placenta Placenta previa Preeclampsia Maternal bradycardia

Abruptio placenta Cocaine use increases the risk for vasoconstriction and possible abruptio placenta.

A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect? (Select all that apply.) Yellow sclera Acrocyanosis Posterior fontanel larger than the anterior fontanel Positive Babinski reflex Two umbilical arteries visible

Acrocyanosis Positive Babinski reflex Two umbilical arteries visible Acrocyanosis is correct. Acrocyanosis is an expected finding for at least the first 24 hr following birth. Poor peripheral perfusion leads to bluish discoloration in the newborn's hands and feet. Positive Babinski reflex is correct. Newborns should exhibit a positive Babinski sign following birth. The nurse should stroke the newborn's foot upward from the heel to the toes. The toes should hyperextend, and dorsal flexion of the big toe should occur. The absence of this finding requires neurological evaluation. The Babinski reflex is no longer present after 1 year of age. Two umbilical arteries visible is correct. The nurse should observe two arteries and one vein in the umbilical cord. The presence of only one artery can indicate a renal anomaly.

A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect? Deep tendon reflexes 4+ Fundal height 14 cm Urine protein 2+ FHR 152/min

FHR 152/min The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation with an average of approximately 160/min at 20 weeks of gestation. Therefore, this is an expected finding by the nurse.

A nurse is caring for a client who is 3 days postpartum. Exhibit 1 Medical History Gravida 1, Para 138 weeks of gestationForceps-assisted birth following failed vacuum-assisted attempt.3rd degree laceration with a repairAmniotic membranes ruptured for 18 hr prior to delivery.Pregnancy complicated by gestational diabetes and anemia. Exhibit 2 Vital Signs Temperature 38.3° C (101° F)Heart rate 104/minRespiratory rate 20/minBlood pressure 108/70 mm Hg Exhibit 3 Nurses' Notes Client states "I feel terrible today. I have this feeling of pain and pressure in my pelvis." Client reports general malaise and chills. Uterus firm at the umbilicus and tender to palpation. Moderate amount of dark foul-smelling lochia noted. Generalized perineal edema observed. Frequently voiding large amounts of urine. Client reports an abdominal pain level of 5 on a scale of 0 to 10. Exhibit 4 Diagnostic Results Hemoglobin 10 mg/dL (12 to 16 mg/dL, pregnant > 11 g/dL)Hematocrit 37% (37 to 47%, pregnant > 33%)WBC count 37,000/mm3 (5,000 to 10,000 mm3​) Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. See image

The nurse should plan to obtain a culture of vaginal fluid and to administer IV antibiotics because the client is most likely experiencing endometritis as evidenced by increased pelvic pain, pressure and tenderness, fever, and foul-smelling vaginal discharge. The client had an increased risk of developing endometritis due to the history of anemia, gestational diabetes, operative vaginal birth, and prolonged rupture of membranes. The nurse should plan to monitor the client's temperature and the amount and odor of the lochia. Clients who have endometritis have an increased risk of hemorrhage. A decrease of foul-smelling lochia and fever indicate progression toward resolution of the infection.

A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider? Blood pressure 136/88 mm Hg Report of insomnia Weight gain of 2.2 kg (4.8 lb) Report of Braxton Hicks contractions

Weight gain of 2.2 kg (4.8 lb) A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could indicate complications. Therefore, this finding should be reported to the provider.

A nurse in a clinic is caring for a 16-year-old adolescent. Exhibit 1 History and Physical Adolescent is sexually active with two current partners.IUD in placeReports not using condoms during sexual activity.History of type 1 diabetes mellitus Exhibit 2 Nurses' Notes 1300:Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on 0 to 10 pain scale and describes pain as constant and dull. Reports nausea and vomiting over past 24 hours.Reports painful urination and pain during sexual intercourse with minimal vaginal itching.Tenderness with palpation to lower abdomen, guarding abdomen observed. Greenish vaginal discharge observed. Reports last menstrual period was 3 weeks ago as normal period lasted 4 days. Exhibit 3 Vital Signs 1300:Blood pressure 118/72 mm HgHeart rate 100/minRespiratory rate 20/minTemperature 38.3° C (101° F) Exhibit 4 Provider Prescriptions 1300:Standing prescriptions for clients who present with abdominal pain:Obtain laboratory tests:UrinalysisCervical cultureC-reactive proteinBeta hCG Which of the following findings should the nurse report to the provider? Select all that apply. Abdominal assessment Vaginal discharge Heart rate Temperature Dyspareunia Condom usage

Abdominal assessment Vaginal discharge Temperature Dyspareunia Condom usage Abdominal assessment is correct. Abdominal tenderness with palpation is not an expected finding with an abdominal assessment; therefore, the nurse should report this finding to the provider. Vaginal discharge is correct. Greenish vaginal discharge indicates that the adolescent has an infection, which is not an expected finding; therefore, the nurse should report this finding to the provider. Temperature is correct. The client's temperature of 38.3° C (101° F) is above the expected reference range. An elevated temperature could signal infection or inflammation; therefore, the nurse should report this finding to the provider. Dyspareunia is correct. Dyspareunia is painful intercourse, which can be associated with STIs; therefore, the nurse should report this finding to the provider. Condom usage is correct. Sexual activity without the use of condoms increases the risk of contracting STIs; therefore, the nurse should report this finding to the provider.

A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take immediately after the seizure? Monitor the FHR. Assess uterine activity. Administer oxygen via a nonrebreather mask. Start a bolus of IV fluids.

Administer oxygen via a nonrebreather mask. When using the airway, breathing, and circulation approach to client care, the nurse should place the priority on administering oxygen to the client via a nonrebreather mask at 10 L/min to ensure adequate oxygenation to the fetus.

A nurse is caring for a client who is pregnant. Exhibit 1 Medical History Gravida 1, Para 041 weeks of gestationInduction of labor due to postdates Exhibit 2 Nurses' Notes 1400:Client received epidural anesthesia for reports of a pain level of 7 on a scale of 0 to 10 from uterine contractions.Contractions occurring every 4 to 5 min, lasting 60 seconds, palpate moderate.FHR: Baseline 135/min, average variability, accelerations present, no decelerations noted.Oxytocin infusing at 8 milliunit/min. Rate last increased by 2 milliunits/min at 1330. 1415: Client reports feeling light-headed.Contractions occurring every 4 to 5 min, lasting 60 seconds, palpate moderateFHR: Prolonged deceleration of fetal heart rate to 90/min, minimal variability. Exhibit 3 Vital Signs 1400: Temperature 37.1° C (98.8° F)Heart rate 72/minRespirations16/minBlood pressure 128/76 mm HgOxygen saturation 96%1415:Heart rate 90/minRespiratory rate 20/minBlood pressure 92/50 mm HgOxygen saturation 96% Which of the following actions are the nurse's priorities? Select the 4 actions that the nurse should take immediately. Assess cervical dilation. Administer a bolus of IV fluids. Insert an indwelling urinary catheter. Reposition the client to their side. Apply oxygen at 10 to 12 L/min by nonrebreather mask. Elevate the client's legs. Evaluate the client's pain level.

Administer a bolus of IV fluids. Reposition the client to their side. Apply oxygen at 10 to 12 L/min by nonrebreather mask. Elevate the client's legs. Administer a bolus of IV fluids is correct. A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the client's hypotension and fetal bradycardia and minimal variability. The nurse should plan to administer a bolus of IV fluids to increase the client's blood volume and improve uterine and intervillous space blood flow. Reposition the client to their side is correct. A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the fetal bradycardia and minimal variability caused by decreased uteroplacental perfusion. The nurse should plan to turn the client to their side to increase cardiac output and improve uterine and intervillous space blood flow. Apply oxygen at 10 to 12 L/min by nonrebreather mask is correct. A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the fetal bradycardia and minimal variability caused by decreased uteroplacental perfusion. The nurse should plan to administer oxygen via nonrebreather mask to increase maternal circulating oxygen levels and improve oxygen transfer through the intervillous spaces to the fetus. Elevate the client's legs is correct. A priority intervention that the nurse should perform when using the urgent vs. nonurgent approach to client care is to address the client's hypotension and fetal bradycardia and minimal variability. Elevating the client's legs will promote blood return to the heart and increase cardiac output. This action will improve uterine and intervillous space blood flow.

A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider? BUN 25 mg/dL Serum creatinine 0.8 mg/dL Urine output of 280 mL within 8 hr Urine negative for ketones

BUN 25 mg/dL The nurse should report an elevated BUN to the provider since it can indicate dehydration.

A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke." Which of the following interventions is the nurse's priority? Perform Nitrazine testing. Assess the fluid. Check cervical dilation. Begin FHR monitoring.

Begin FHR monitoring. The greatest risk to the client and her fetus following a rupture of membranes is umbilical cord prolapse. The nurse should monitor the fetus closely to ensure well-being. Therefore, this is the priority action the nurse should take.

A nurse is caring for a newborn who is 70 hr old. Exhibit 1 Medical History Newborn delivered by repeat cesarean birth at 40 weeks of gestation.Birth weight 7 lb 12 oz (3,515 g)Apgar scores 8 at 1 min and 9 at 5 minMaternal history of methadone use during pregnancy. Exhibit 2 Vital Signs 0700:Heart rate 156/minRespiratory rate 58/minTemperature 37.2° C (98.9° F) Oxygen saturation 98% on room air1100:Heart rate 160/minRespiratory rate 60/minTemperature 37.3° C (99.2° F) Oxygen saturation 96% on room air Exhibit 3 Physical Examination 1100:Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier but breastfeeds poorly. Respirations unlabored. Lungs sound clear on auscultation. Increased muscle tone with moderate to severe tremors when disturbed. Hyperactive Moro reflex noted. Several loose stools today. Exhibit 4 Diagnostic Results Maternal urine toxicology screen positive for opiates (negative)Newborn urine toxicology screen positive for opiates (negative) Which of the following findings should the nurse report to the provider? Select all that apply. Respiratory findings Temperature Oxygen saturation Central nervous system findings Gastrointestinal findings

Central nervous system findings Gastrointestinal findings Central nervous system findings is correct. The newborn is displaying inconsolability, high-pitched cry, increased muscle tone, tremors, hyperactive Moro reflex, and excessive sucking. These findings are manifestations of NAS and should be reported to the provider. Gastrointestinal findings is correct. The newborn is displaying poor feeding and loose stools. These findings are manifestations of NAS and should be reported to the provider.

A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure? Check the client's temperature. Observe for uterine contractions. Administer Rho(D) immune globulin. Monitor the FHR.

Monitor the FHR. The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing intervention is to monitor the FHR following an amniocentesis.

A nurse in a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia? Singleton pregnancy BMI of 20 Maternal age 32 years Pregestational diabetes mellitus

Pregestational diabetes mellitus Pregestational diabetes mellitus increases a client's risk for the development of preeclampsia. Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus, and rheumatoid arthritis.

A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care? Protect the client's head and feet from cold air. Bathe the client within 12 hr following birth. Ambulate the client within 24 hr following birth. Offer the client a glass of cold milk with her first meal.

Protect the client's head and feet from cold air. Protecting the client's head and feet from cold air should be included in the plan of care because this is a traditional Hispanic practice during the postpartum period.

A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan? Feed the newborn 1 oz of water every 4 hr. Apply lotion to the newborn's skin three times per day. Remove all clothing from the newborn except the diaper. Discontinue therapy if the newborn develops a rash.

Remove all clothing from the newborn except the diaper. The nurse should remove all the newborn's clothing except the diaper while under phototherapy. Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin.

A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect? Reports increased urinary output Diaphoresis Reports blurred vision Shallow respirations

Reports increased urinary output Increased urinary output, nausea and vomiting, reports of thirst, abdominal pain, constipation, drowsiness, and headaches are manifestations of hyperglycemia. Other manifestations include weak rapid pulse, fruity breath odor, urine positive for sugar and acetone, and a blood glucose level greater than 200 mg/dL.

A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia? Hypertonia Increased feeding Hyperthermia Respiratory distress

Respiratory distress Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia. Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor feeding, apnea, and seizures.

A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects? Client reports nausea Urinary output of 40 mL/hr Respiratory rate 10/min Client reports feeling flushed

Respiratory rate 10/min The nurse should report a respiratory rate of less than 12/min to the provider, because this is a manifestation of magnesium toxicity. The nurse should ensure that the antidote, calcium gluconate, is readily available.

A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching? -"Obtain an informed consent prior to obtaining the specimen." -"Collect at least 1 milliliter of urine for the test." -"Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." -"Premature newborns may have false negative tests due to immature development of liver

"Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining the specimen." The nurse should ensure that the newborn has been receiving regular feedings for at least 24 hr prior to testing.

A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching? "I can administer oxytocin 4 hours after the insertion of the medication." "You will need a full bladder prior to the insertion of the medication." "Remain in a side-lying position for 15 minutes after the medication is inserted." "An antacid will be given 20 minutes prior to the insertion of the medication."

"I can administer oxytocin 4 hours after the insertion of the medication." The nurse can administer oxytocin no sooner than 4 hr after the last dose of misoprostol. Oxytocin can be administered following misoprostol for clients who have cervical ripening and have not begun labor.

A nurse is reviewing the provider's prescription in the adolescent's medical chart. Exhibit 1 History and Physical Adolescent is sexually active with two current partners. IUD in place Reports not using condoms during sexual activity. History of type 1 diabetes mellitus Exhibit 2 Nurses' Notes 1300:Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on 0 to 10 pain scale and describes pain as constant and dull. Reports nausea and vomiting over past 24 hours.Reports painful urination and pain during sexual intercourse with minimal vaginal itching.Tenderness with palpation to lower abdomen, guarding abdomen observed. Greenish vaginal discharge observed.Reports last menstrual period was 3 weeks ago as normal period that lasted 4 days Exhibit 3 Vital Signs 1300: Blood pressure 118/72 mm Hg Heart rate 100/min Respiratory rate 20/min Temperature 38.3° C (101° F) Exhibit 4 Provider Prescriptions 1300:Standing prescriptions for clients who present with abdominal pain: Obtain laboratory tests: UrinalysisCervical culture C-reactive protein Beta hCG 1400:Ceftriaxone 250 mg IM stat Discharge prescriptions: Doxycycline 100 mg tab PO twice daily for 7 days Metronidazole 500 mg PO twice daily for 14 days Ondansetron 8 mg sublingual tab every 8 hr PRN nausea Ibuprofen 400 mg tab PO every 4 to 6 hr PRN pain Exhibit 5 Diagnostic Results 1335: Urinalysis: Appearance clear (clear) Color amber yellow (amber yellow) pH 6.5 (4.6 to 8.0) Leukocyte esterase negative (negative) WBC count 0 (0 to 4) Nitrites none (none) Cervical culture pending C-reactive protein 12.2 mg/dL (<1.0 mg/dL) Beta hCG 3 IU/L negative (<5 IU/L) Exhibit 6 Progress Report 1410: 16-year-old sexually active adolescent who reports having unprotected sex. Reports cramping pain in lower abdomen, tender with palpation. Reports painful urination and pain during sex. Vaginal and pelvic exams reveal greenish, thick vaginal discharge, swollen and red labia. Treat adolescent for gonorrhea and mild PID: ceftriaxone to be given in clinic. Discharge instructions and prescriptions include doxycycline, metronidazole, ondansetron, ibuprofen. Instruct to complete all medications. Refrain from sex until treatment is complete. All partners should be notified and be treated for infection. Counsel regarding condom use. Discuss complications of reinfection and when to see provider. Return to office in 1 month. The nurse has just reviewed discharge instructions with the adolescent. Which of the following indicates whether the adolescent understands the teaching or requires further education? For each of the statements made by the adolescent, click to specify whether the statement indicates an understanding or requires further education. see image

"I should continue taking all my medications even if I don't show any symptoms" indicates an understanding of the teaching. The nurse instructed the adolescent to complete all of their medications, even if they begin to feel better. "If I continue to get this type of infection, it can affect my ability to have kids in the future" indicates an understanding of the teaching. The nurse instructed the adolescent that repeated instances of PID can cause infertility. "I should go to the emergency department if my urine turns dark" indicates the need for further education. The nurse informed the adolescent that while taking metronidazole their urine might turn dark, they should not be alarmed because dark urine is an adverse effect of taking this medication. "As long as I keep my IUD, I don't need to use condoms" indicates the need for further education. The nurse informed the adolescent that they should use a condom to decrease the risk of contracting an STI; IUDs effectively prevent pregnancy, not STIs. "I'm more likely to get a sunburn while taking these medications" indicates an understanding of the teaching. The nurse informed the adolescent that they might experience increased sensitivity to sunlight while using doxycycline and that they should use sunscreen and wear protective clothing while taking the medication.

A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching? "I should increase my protein intake to 60 grams each day." "I should drink 2 liters of water each day." "I should increase my overall daily caloric intake by 300 calories." "I should take 600 micrograms of folic acid each day."

"I should take 600 micrograms of folic acid each day." A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects.

A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching? "I will not gain more than 15 to 20 pounds during my pregnancy." "I will likely need to use alternative positions for sexual intercourse." "I'm glad I had a breast reduction years ago, so they will not enlarge with my pregnancy." "I'm glad I have a light complexion and will not get any stretch marks."

"I will likely need to use alternative positions for sexual intercourse." The weight gain of pregnancy will likely require alternative positions for sexual intercourse. This client statement indicates that she understands the nurse's teaching about the physiological changes that occur during pregnancy.

A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching? -"My sister will be able to carry my baby from the nursery to my room when she arrives." -"The nurse will match my wrist band to my baby's crib card when they bring him to me." -"The person who comes to take my baby's pictures will be wearing a photo identification badge." -"My baby doesn't need to wear the electronic security bracelet when he's in my room."

"The person who comes to take my baby's pictures will be wearing a photo identification badge." All personnel working on the unit should be wearing a photo identification badge. The nurse should instruct the parent to never allow anyone who is not wearing an identification badge to come in contact with the newborn.

A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instructions should the nurse include? "You can resume sexual activity in 1 week." "You won't need to do Kegel exercises since you had a cesarean." "You can still become pregnant if you are breastfeeding." "You are safe to start adding sit-ups to your exercise routine in 2 weeks."

"You can still become pregnant if you are breastfeeding." The nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the client can become pregnant. The nurse should discuss contraception that is safe to use while breastfeeding.

A nurse is caring for a newborn who is 72 hr old. Exhibit 1 Medical History Newborn delivered by repeat cesarean birth at 40 weeks of gestation.Birth weight 7 lb 12 oz (3,515 g)Apgar scores 8 at 1 min and 9 at 5 minMaternal history of methadone use during pregnancy. Exhibit 2 Vital Signs 0700:Heart rate 156/minRespiratory rate 68/minTemperature 37.7° C (99.9° F) Oxygen saturation 97% on room air1100:Heart rate 174/minRespiratory rate 84/minTemperature 38.2° C (100.8° F) Oxygen saturation 98% on room air Exhibit 3 Physical Examination 1100:Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously on pacifier but breastfeeds poorly. Increased muscle tone with moderate to severe tremors when disturbed. Hyperactive Moro reflex noted. Mottled skin noted on extremities. Frequent sneezing. Several loose stools today. Exhibit 4 Diagnostic Results Maternal urine toxicology screen: positive for opiates (negative) The nurse is planning to contact the provider regarding the newborn's status. Which of the following prescriptions regarding the newborn should the nurse anticipate? Select all that apply. Instruct the mother to discontinue breastfeeding. Administer scheduled doses of oral morphine. Give a one-time dose of naloxone IM. Maintain a low-stimulus environment. Initiate neonatal abstinence syndrome (NAS) scoring.

-Administer scheduled doses of oral morphine. -Maintain a low-stimulus environment. -Initiate neonatal abstinence syndrome (NAS) scoring. Administer scheduled doses of oral morphine is correct. The nurse should administer scheduled doses of oral morphine to the newborn to decrease manifestations of withdrawal. The dosage of the medication is adjusted based on the NAS score of the newborn. Maintain a low-stimulus environment is correct. Supportive care for a newborn who has NAS includes maintaining a low-stimulus environment to help prevent exacerbation of withdrawal manifestations. Initiate neonatal abstinence syndrome (NAS) scoring is correct. The nurse should initiate NAS scoring to evaluate the severity of the newborn's withdrawal manifestations. The score obtained will be used to evaluate the need to titrate the prescription for the morphine dosage.

The nurse is reviewing laboratory results in the adolescent's medical record. Exhibit 1 History and Physical Adolescent is sexually active with two current partners.IUD in placeReports not using condoms during sexual activity.History of type 1 diabetes mellitus Exhibit 2 Nurses' Notes 1300:Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on 0 to 10 pain scale and describes pain as constant and dull. Reports nausea and vomiting over past 24 hours.Reports painful urination and pain during sexual intercourse with minimal vaginal itching.Tenderness with palpation to lower abdomen, guarding abdomen observed. Greenish vaginal discharge observed.Reports last menstrual period was 3 weeks ago as normal period lasted 4 days. Exhibit 3 Vital Signs 1300:Blood pressure 118/72 mm HgHeart rate 100/minRespiratory rate 20/minTemperature 38.3° C (101° F) Exhibit 4 Provider Prescriptions 1300:Standing prescriptions for clients who present with abdominal pain:Obtain laboratory tests:UrinalysisCervical cultureC-reactive proteinBeta hCG Exhibit 5 Diagnostic Results 1335:Urinalysis:Appearance clear (clear)Color amber yellow (amber yellow)pH 6.5 (4.6 to 8.0)Leukocyte esterase negative (negative)WBC count 0 (0 to 4)Nitrites none (none)Cervical culture pendingC-reactive protein 12.2 mg/dL (<1.0 mg/dL)Beta hCG 3 IU/L negative (<5 IU/L) The nurse is reviewing the adolescent's medical record. Which of the following conditions is the client most likely developing? Complete the following sentence by using the list of options. The adolescent is most likely developing -pelvic inflammatory disease -ectopic pregnancy -pyelonephritis as evidenced by -beta hCG level -urinalysis -C-reactive protein

1. pelvic inflammatory disease 2. beta hCG level Pelvic inflammatory disease is correct. Pelvic inflammatory disease (PID) is an infection that involves the pelvic reproductive organs. There are several causative agents that lead to infection, including Neisseria gonorrhoeae and C. trachomatis. PID occurs as a result from untreated infections ascending from the vagina.. Manifestations include fever, increased C-reactive protein, nausea, and vomiting; therefore, the nurse should suspect the adolescent is developing PID C-reactive protein is correct. The adolescent's C-reactive protein is elevated, which is a manifestation of PID.

A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse expect? Decreased uterine contractions An increase in the client's hemoglobin levels A reduction in respiratory distress in the newborn Increased production of antibodies in the newborn

A reduction in respiratory distress in the newborn Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent respiratory distress.

A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.) 1. Clean the newborn's diaper area. 2. Wash the newborn's neck by lifting the newborn's chin. 3. Wipe the newborn's eyes from the inner canthus outward. 4. Cleanse the skin around the newborn's umbilical cord stump. 5. Wash the newborn's legs and feet

3. Wipe the newborn's eyes from the inner canthus outward. 2. Wash the newborn's neck by lifting the newborn's chin. 4. Cleanse the skin around the newborn's umbilical cord stump 5. Wash the newborn's legs and feet 1. Clean the newborn's diaper area.

A nurse is preparing to administer magnesium sulfate 2 g/hr IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 mL of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) mL/hr??

50mL/hr

A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first? A client who is at 11 weeks of gestation and reports abdominal cramping A client who is at 15 weeks of gestation and reports tingling and numbness in right hand A client who is at 20 weeks of gestation and reports constipation for the past 4 days A client who is at 8 weeks of gestation and reports having three bloody noses in the past week

A client who is at 11 weeks of gestation and reports abdominal cramping When using the urgent vs nonurgent approach to client care, the nurse should determine that the priority finding is a client who is at 11 weeks of gestation and reports abdominal cramping. Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous abortion. The nurse should request that the provider see this client first.

A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider? A newborn who is 26 hr old and has erythema toxicum on his face A newborn who is 32 hr old and has not passed a meconium stool A newborn who is 12 hr old and has pink-tinged urine A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F)

A newborn who is 18 hr old and has an axillary temperature of 37.7° C (99.9° F) An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to the provider.

A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption. Which of the following laboratory tests should the nurse expect the provider to prescribe? A. Kleihauer-Betke test B. Progesterone serum level C. Lecithin/sphingomyelin (L/S) ratio D. Maternal Alpha-fetoprotein (AFP)

A. Kleihauer-Betke test The nurse should expect the provider to prescribe a Kleihauer-Betke test for a client who has suspected placental abruption to determine if fetal blood is in maternal circulation. This test is useful to determine if Rho-(D) immune globulin therapy should be administered to a client who is Rh-negative.

A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client develops magnesium toxicity? Calcium gluconate Hydralazine Medroxyprogesterone acetate Methylergonovine

Calcium gluconate The nurse should anticipate administering calcium gluconate if the client develops magnesium toxicity. Calcium gluconate is the antidote.

A nurse is providing teaching about nonpharmacological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items? Cold cabbage leaves Purified lanolin cream A snug-fitting support bra Breast shells

Cold cabbage leaves The application of fresh, raw cabbage leaves that have been chilled is an effective nonpharmacological method to relieve the pain associated with engorgement. The nurse should instruct the client to place the cabbage leaves on the breasts for 15 to 20 min, repeating the application for two to three sessions as needed. More frequent applications could decrease the client's milk supply.

A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication? Depression Polyuria Hypotension Urticaria

Depression The nurse should instruct the client that depression is a common adverse effect of combined oral contraceptives. Other common adverse effects of the medication include amenorrhea, weight gain, headache, nausea, breakthrough bleeding, and breast tenderness.

The nurse is reviewing laboratory results in the adolescent's medical record. Exhibit 1 History and Physical Adolescent is sexually active with two current partners.IUD in placeReports not using condoms during sexual activity.History of type 1 diabetes mellitus Exhibit 2 Nurses' Notes 1300:Admitted adolescent reporting "cramping in my stomach." Reports pain as a 4 on 0 to 10 pain scale and describes pain as constant and dull. Reports nausea and vomiting over past 24 hours.Reports painful urination and pain during sexual intercourse with minimal vaginal itching.Tenderness with palpation to lower abdomen, guarding abdomen observed. Greenish vaginal discharge observed. Reports last menstrual period was 3 weeks ago as normal period lasted 4 days. Exhibit 3 Vital Signs 1300:Blood pressure 118/72 mm HgHeart rate 100/minRespiratory rate 20/minTemperature 38.3° C (101° F) Exhibit 4 Provider Prescriptions 1300:Standing prescriptions for clients who present with abdominal pain:Obtain laboratory tests:UrinalysisCervical cultureC-reactive proteinBeta hCG Exhibit 5 Diagnostic Results 1335:Urinalysis:Appearance clear (clear)Color amber yellow (amber yellow)pH 6.5 (4.6 to 8.0)Leukocyte esterase negative (negative)WBC count 0 (0 to 4)Nitrites none (none)Cervical culture pendingC-reactive protein 12.2 mg/dL (<1.0 mg/dL)Beta hCG 3 IU/L negative (<5 IU/L) The nurse is planning care for the adolescent. Which of the following prescriptions should the nurse expect the provider to prescribe? Drag words from the choices below to fill in each blank in the following sentence. The nurse should anticipate a provider's prescription for Target 1: Doxycycline Fluconazole Imiquimod Ceftriaxone Acyclovir and Doxycycline Fluconazole Imiquimod Ceftriaxone Acyclovir Target 2:

Doxycycline Ceftriaxone Ceftriaxone and doxycycline are correct. Ceftriaxone is an anti-infective used to treat a variety of infections, including gonorrheal infection. Ceftriaxone is administered as a one-time IM injection for the treatment of gonorrhea. The adolescent is exhibiting manifestations of a gonorrheal infection. Therefore, the nurse should anticipate a provider's prescription for ceftriaxone. Doxycycline is an anti-infective used to treat a variety of infections. Doxycycline and ceftriaxone are anti-infectives used in the treatment of mild to moderate PID. The adolescent is exhibiting manifestations of a gonorrheal infection and PID. Therefore, the nurse should anticipate a provider's prescription for doxycycline.

A nurse is caring for a newborn. Exhibit 1 Medical History 1600:Apgar Score 9 at 1 min and 9 at 5 minBirth weight 10 lb 6 oz (4706 gm)Gestational age 40 weeksDifficult vaginal birth with shoulder dystocia. Exhibit 2 Nurses' Notes 1700:Newborn is active and moves all extremities except for right arm. No spontaneous movement of the right arm noted. Right arm remains at side during Moro reflex. Exhibit 3 Physical Examination 1830:Absent Moro reflex noted in right arm.Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm pronated with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's palsy) paralysis. Which of the following actions should the nurse plan to implement? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the newborn. see image

Educate the parents to begin range of motion exercises on the affected arm after 1 week is indicated. Passive ROM exercises of the arm are indicated to restore function of the extremity. The initiation of these exercises is delayed for approximately 1 week to prevent additional injury to the brachial plexus. Assess for grasp reflex in the affected extremity is indicated. With Erb-Duchenne paralysis, only the upper arm is affected. The function of the wrists and fingers should be unaffected; the nurse should assess for a palmar grasp reflex. Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt is indicated. Intermittent immobilization of the affected arm across the newborn's abdomen can be achieved by pinning the sleeve to the shirt. Instruct parents to limit physical handling for 2 weeks is contraindicated. Parents and guardians should participate in the physical care of their newborn to increase parental-infant attachment. Providing education and practice opportunities for the parents will decrease their fears of injuring the newborn and increase confidence and bonding.

Exhibit 1 Graphic Record​ Blood pressure 130/78 mm Hg Respiratory rate 20/min Heart rate 90/min Exhibit 2 Diagnostic Results​ Hemoglobin 12 g/dL Hematocrit 34% 1-hr glucose tolerance test 120 mg/dL Exhibit 3 Progress Notes Fundal height 30 cm Good fetal movement Not experiencing headache, dizziness, blurred vision, or vaginal bleeding Fetal heart rate 110/min A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) 1-hr glucose tolerance test Hematocrit Fundal height measurement Fetal heart rate (FHR)

Fundal height measurement A fundal height measurement of 30 cm should be reported to the provider. Fundal height should be measured in centimeters and is the same as the number of gestational weeks plus or minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the provider.

A nurse is reviewing the prenatal laboratory results for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider? Hemoglobin 10 g/dL WBC count 10,000/mm3 Platelets 250,000/mm3 Fasting blood glucose 90 mg/dL

Hemoglobin 10 g/dL A hemoglobin of 10 g/dL is below the expected reference range of greater than 11 g/dL for a client who is pregnant. The nurse should report this finding to the provider to obtain a prescription for ferrous iron supplementation because of anemia.

A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? Determine progression of dilatation and effacement. Perform Leopold maneuvers. Complete a sterile speculum exam. Prepare a Nitrazine paper test.

Perform Leopold maneuvers. The nurse should perform Leopold maneuvers to assess the position of the fetus to best determine the optimal placement for the external fetal monitoring transducer.

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take? Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. Wrap the visible cord tightly with sterile, dry gauze. Apply oxygen to the client at 2 L/min via nasal cannula. Place the client in the lithotomy position and apply fundal pressure.

Insert two gloved fingers into the vagina and apply upward pressure to the presenting part. The nurse should quickly apply gloves and insert two fingers into the vagina toward the cervix, exerting upward pressure onto the presenting part to relieve umbilical cord compression and increase oxygenation to the fetus.

A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider? Acrocyanosis Transient strabismus Jaundice Caput succedaneum

Jaundice Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility, hemolysis, or Rh-isoimmunization. The nurse should report this manifestation to the provider.

A nurse is observing a new parent caring for their crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior? Lays the newborn across their lap and gently sways Places the newborn in the crib in a prone position Offers the newborn a pacifier dipped in formula Prepares a bottle of formula mixed with rice cereal

Lays the newborn across their lap and gently sways This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn.

A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect? Minimal arm recoil Popliteal angle of 90° Creases over the entire foot sole Raised areolas with 3 to 4 mm buds

Minimal arm recoil The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased muscular tone, or minimal arm recoil.

A nurse is assessing a client who is receiving morphine via IV bolus for pain following a cesarean birth. The nurse notes a respiratory rate of 8/min. Which of the following medications should the nurse administer? Fentanyl Butorphanol Naloxone Meperidine

Naloxone Morphine is a common opioid analgesic used for postoperative pain management that can cause central nervous system depression and can cause respiratory depression. The nurse should administer naloxone, an opioid antagonist, to reverse the opioid-induced respiratory depression in the client.

A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? Apply a cool pack for 10 min to the heel prior to the puncture. Request a prescription for IM analgesic. Use a manual lance blade to pierce the skin. Place the newborn skin to skin on the mother's chest.

Place the newborn skin to skin on the mother's chest. Placing the newborn skin to skin on the mother's chest is an effective technique to significantly decrease the newborn's pain level and anxiety. The nurse should implement this technique before, during, and after the procedure.

A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take? Administer antiviral medication. Schedule an ultrasound examination. Administer Haemophilus influenzae type b vaccine. Schedule an indirect Coombs' test.

Schedule an ultrasound examination. The nurse should schedule serial ultrasound examinations to monitor the fetus during the pregnancy to detect the possible development of fetal hydrops. Also, the virus can cause miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth.

A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound? To estimate the fetal weight To locate a pocket of fluid To determine multiparity To prescreen for fetal anomalies

To locate a pocket of fluid An ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an amniocentesis. This decreases the risk of injury to the fetus.

A nurse is caring for a client who is pregnant in an antepartum clinic. Exhibit 1 Exhibit 2 Exhibit 3 Vital Signs 0900:Temperature 36.6° C (97.9° F)Heart rate 88/minRespiratory rate 18/minBlood pressure 130/70 mm HgOxygen saturation 97% on room air1000:Heart rate 76/minRespiratory rate 20/minBlood pressure 138/68 mm HgOxygen saturation 98% on room air Medical History 0900:Gravida 3, Para 232 weeks of gestationClient reports cramping and lower back pain that started this morning. Client denies leaking fluid. Nurses' Notes 0900:Client placed on electronic fetal monitor. Client reports pain as 4 on a scale of 0 to 10. 1000:FHR assessment 150/min. Average variability. No decelerations. Spontaneous accelerations noted.Uterine contractions occurring every 2 min, lasting 40 to 60 seconds in duration. Palpate as moderate intensity.Vaginal examination performed. Cervix is 2 cm dilated and 50% effaced. Which of the following findings should the nurse report to the provider? Select the 3 findings that should be reported. Uterine contractions Fetal heart rate Gestational age Vaginal examination Maternal blood pressure

Uterine contractions is correct. The client is experiencing regular uterine contractions and cervical change, which are indicators of preterm labor; therefore, the nurse should notify the provider about this finding. Fetal heart rate is incorrect. The fetal heart rate is within the expected reference range; therefore, the nurse should not report this finding to the provider. Gestational age is correct. The client is at 32 weeks of gestation and is experiencing regular uterine contractions and cervical dilation, which indicates that the client is in preterm labor; therefore, the nurse should notify the provider about this finding. Vaginal examination is correct. The client's cervix is dilated to 2 cm and is 50% effaced, which indicate the client is in preterm labor; therefore, the nurse should notify the provider about this finding. Maternal blood pressure is incorrect. The client's blood pressure is within the expected reference range; therefore, the nurse should not report this finding to the provider.

A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect? Lochia serosa vaginal drainage Vaginal pressure Intermittent vaginal pain Yellow exudate vaginal drainage

Vaginal pressure The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina due to the blood that leaked into the tissues.

A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take? Verify that the parent's identification band matches the newborn's identification band. Scan the newborn's identification band to verify their identity. Check the newborn's security tag number to ensure it matches the newborn's medical record. Match the newborn's date and time of birth to the information in the parent's medical record.

Verify that the parent's identification band matches the newborn's identification band. The nurse should verify the newborn's identity every time the newborn is returned to the parents. The nurse should match the information on the parent's identification band to the information on the newborn's identification band.