Rn maternal newborn practice 2023A

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.

C-reactive protein Pelvic inflammatory disease

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?

Monitor the FHR

A nurse is preparing to administer oxytocin to a client who is postpartum. Which of the following findings is an indication for the administration of the medication? (Select all that apply.)

flaccid uterus and excess vaginal bleeding

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.

"I should continue taking all my medications even if I don't show any symptoms." ndicates an understanding "If I continue to get this type of infection, it can affect my ability to have kids in the future." indicates an understanding "I should go to the emergency department if my urine turns dark." requires further education. "As long as I keep my IUD, I don't need to use condoms." requires further education. "I'm more likely to get a sunburn while taking these medications." indicates an understanding

A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching?

"I will eat foods that taste good instead of balancing my meals." Clients who have hyperemesis gravidarum should eat foods they like in order to avoid nausea, rather than trying to consume a well-balanced diet.

A nurse is teaching a postpartum client about steps the nurses will take to promote the security and safety of the client's newborn. Which of the following statements should the nurse make?

"Staff members who take care of your baby will be wearing a photo identification badge."

A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress test. Which of the following instructions should the nurse include?

"You should press the handheld button when you feel your baby move." Rationale: The nurse should instruct the client to press the handheld button when the fetus moves. This action will mark the fetal monitor tracing with the client's reports of fetal movement. This will assist in the interpretation of the nonstress test to determine if it is reactive or nonreactive. Other interventions: - The nurse should instruct the client to be positioned in a reclining chair or semi-Fowler's position with a slight lateral tilt to ensure optimal uterine perfusion. - The client is not required to be NPO before or during the procedure. The nurse can suggest the client drink orange juice to increase their blood glucose level which will stimulate fetal movements. - The nurse should instruct the client that the nonstress will take approximately 20 to 30 min, but more time might be required if the fetus is in a sleep state when the testing begins.

A NURSE IS CARING FOR A CLIENT WHO IS PREGNANT IN AN ANTEPARTUM clinic. Which of the following findings should the nurse report to the provider?

- Uterine contractions. 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. - Gestational age. 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. 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. The client's blood pressure is within the expected reference range . Blood pressure 130/70 mm Hg? what is normal.

A nurse is preparing to perform Leopold maneuvers for a client. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

1. Palpate the fundus to identify fetal part 2. Determine the location of the fetal back 3. Palpate for fetal part presenting at the inlet 4. Identify the attitude of the head

A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states "Administer azithromycin 1 g orally now." Available are 250 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

4 tabs 1g x 1000mg = 1000mg 1000mg/250mg = 4 tabs

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 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?

A client who is pregnant should increase her folic acid intake to 600 mcg daily. Folic acid assists with preventing neural tube birth defects. A client who is pregnant should increase her caloric intake by 340 cal during the second trimester and by 452 cal during the third trimester. A client who is pregnant should consume 3 L of water each day. A client who is pregnant should increase her protein intake to 71 g each day during the second and third trimesters.

A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?

A newborn who is 18 hr old and has an axillary temperature of 99.9° F

A nurse on an antepartum unit is caring for four clients. Which of the following clients should the nurse identify as the priority?

A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL B. A client who is at 34 weeks of gestation and reports epigastric pain C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria Answer: A client who is at 34 weeks of gestation and reports epigastric pain A. A client who has gestational diabetes and a fasting blood glucose level of 120 mg/dL A fasting blood glucose of 120 mg/dL is above the expected reference range for a client who has gestational diabetes, which is a nonurgent finding. Therefore, another client is the nurse's priority. B. A client who is at 34 weeks of gestation and reports epigastric pain When using the urgent vs nonurgent approach to client care, the nurse should assess the client who reports epigastric pain. Epigastric pain is a manifestation of preeclampsia and indicates hepatic involvement, which is an urgent finding. Therefore, the nurse should identify this client as the priority. C. A client who is at 28 weeks of gestation and has an Hgb of 10.4 g/dL This finding is a manifestation of anemia in a client who is pregnant, which is a nonurgent condition. Therefore, another client is the nurse's priority. D. A client who is at 39 weeks of gestation and reports urinary frequency and dysuria Dysuria can indicate a urinary tract infection, which can cause preterm labor. Dysuria in a client who is at 39 weeks of gestation is a nonurgent condition which will require antibiotics. Thereofre, another client is the nurse's priority.

A nurse is caring for a newborn who was transferred to the nursery 30 min after birth because of mild respiratory distress. Which of the following actions should the nurse take first?

A. Confirm the newborn's Apgar score. B. Verify the newborn's identification. C. Administer vitamin K to the newborn. D. Determine obstetrical risk factors. Answer: Verify the newborn's identification. A. Confirm the newborn's Apgar score. The Apgar score is a physiological assessment that occurs 1 min following birth and again at 5 min. The nurse should confirm the score when the newborn arrives in the nursery. However, there is another action the nurse should take first. B. Verify the newborn's identification. When using the safety/risk reduction approach to client care, the first action the nurse should take is to verify the newborn's identity upon arrival to the nursery. C. Administer vitamin K to the newborn. The nurse should administer IM vitamin K to the newborn soon after birth to increase clotting factors and prevent bleeding. However, the injection can be delayed until after initial bonding time and the first breastfeeding if necessary. Therefore, there is another action the nurse should take first. D. Determine obstetrical risk factors. The nurse should identify obstetrical risk factors to determine if interventions are required for the newborn. However, there is another action the nurse should take first.

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?

A. Decreased platelet count B. Increased erythrocyte sedimentation rate (ESR) C. Decreased megakaryocytes D. Increased WBC Answer: Decreased platelet count A. Decreased platelet count A client who has ITP has an autoimmune response that results in a decreased platelet count. B. Increased erythrocyte sedimentation rate (ESR) An increased ESR is an indication of chronic renal failure. C. Decreased megakaryocytes A client who has ITP will have megakaryocytes within the expected reference range. D. Increased WBC An increased WBC is an indication of infection.

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta. Which of the following actions should the nurse take first?

A. Determine respiratory function. B. Increase the IV fluid rate. C. Access emergency medications from cart. D. Collect a maternal blood sample for coagulopathy studies. Answer: Determine respiratory function. A. Determine respiratory function. The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to determine respiratory function and the need for cardiopulmonary resuscitation. B. Increase the IV fluid rate. The nurse should increase the IV fluid rate to maintain circulation. However, this is not the first action the nurse should take. C. Access emergency medications from cart. The nurse should access emergency medication to assist in resuscitative efforts. However, this is not the first action the nurse should take. D.Collect a maternal blood sample for coagulopathy studies. The nurse should collect a maternal blood sample in preparation for a blood transfusion. However, this is not the first action the nurse should take.

A nurse is assessing the newborn of a client who took a selective serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI?

A. Large for gestational age B. Hyperglycemia C. Bradypnea D. Vomiting Answer: Vomiting A. Large for gestational age Low birth weight is an expected manifestation of fetal exposure to SSRIs. B. Hyperglycemia Hypoglycemia is an expected manifestation of fetal exposure to SSRIs. C. Bradypnea Tachypnea is an expected manifestation of fetal exposure to SSRIs. D. Vomiting Expected manifestations associated with fetal exposure to SSRIs include irritability, agitation, tremors, diarrhea, and vomiting. These manifestations typically last 2 days. Answer: Vomiting

A nurse is reviewing the medical record of a newly admitted client who is at 32 weeks of gestation. Which of the following conditions is an indication for fetal assessment using electronic fetal monitoring?

A. Oligohydramnios B. Hyperemesis gravidarum C. Leukorrhea D. Periodic tingling of the fingers Answer: Oligohydramnios A. Oligohydramnios The nurse should identify that oligohydramnios requires further fetal assessment using electronic fetal monitoring. Other conditions that require further assessment include hypertension, diabetes, intrauterine growth restriction, renal disease, decreased fetal movement, previous fetal death, post-term pregnancy, systemic lupus erythematosus, and intrahepatic cholestasis. B. Hyperemesis gravidarum Hyperemesis gravidarum is not an indication for further fetal assessment using electronic fetal monitoring unless complications occur. C. Leukorrhea Leukorrhea is a common finding during pregnancy and is not an indication for further fetal assessment using electronic fetal monitoring unless complications occur. D. Periodic tingling of the fingers Periodic tingling of the fingers is a common finding during pregnancy and is not an indication for further fetal assessment using electronic fetal monitoring.

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test. For which of the following diagnostic tests should the nurse prepare the client?

A. Percutaneous umbilical blood sampling B. Amnioinfusion C. Biophysical profile (BPP) D. Chorionic villus sampling (CVS) Answer: Biophysical profile (BPP) A. Percutaneous umbilical blood sampling Percutaneous umbilical blood sampling, commonly called cordocentesis, is the most common method used for fetal blood sampling and transfusion. This is not a diagnostic test used for clients who have a positive contraction stress test. B. Amnioinfusion An amnioinfusion of normal saline or lactated Ringer's is instilled into the amniotic cavity through a transcervical catheter introduced into the uterus to supplement the amount of amniotic fluid. The instillation reduces the severity of variable decelerations caused by cord compression for clients who are in labor. This is not a diagnostic test used for clients who have a positive contraction stress test. C. Biophysical profile (BPP) The nurse should prepare the client for a BPP to further assess fetal well-being. A positive contraction stress test indicates there is potential uteroplacental insufficiency. A BPP uses a real time ultrasound to visualize physical and physiological characteristics of the fetus and observe for fetal biophysical responses to stimuli. D. Chorionic villus sampling (CVS) CVS is the assessment of a portion of the developing placenta, which is aspirated through a thin sterile catheter inserted through the abdominal wall or intravaginally through the cervix under ultrasound guidance. This procedure is done during the first trimester. This is not a diagnostic test used for clients who have a positive contraction stress test.

A nurse in a clinic is caring for a 16-year-old adolescent. Which of the following finding should the nurse report to provider?

Abdominal assessment Vaginal discharge Temperature Dypareunia Condom usage

Which of the following conditions should the nurs being consistent with the adolescent's assessmer For each finding, click to specify if the assessn are consistent with trichomoniasis, gonorrhea candidiasis. Each finding may support more th disease process.

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 caring for a client who is in labor and reports increasing rectal pressure. They are experiencing contractions 2 to 3 min apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that their cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor?

Active Rationale: The nurse should identify that the client is in the active phase of labor. This phase is characterized by a cervical dilatation of 6 to 10 cm and contractions every 1.5 to 5 min, each lasting 40 to 90 seconds. Other considerations: - The early phase of labor is characterized by cervical dilation of 0 to 5 cm and contractions every 2 to 30 min, each lasting 30 to 40 seconds. - The passive descent phase of labor is in the second stage of labor and is characterized by a period of calm and rest. The fetus continues to descend and rotate through the birth canal. - The descent phase of labor is characterized by active pushing with contractions every 1 to 2 min, each lasting for 90 seconds.

A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

Answer: "I will continue taking my insulin if I experience nausea and vomiting." C. "I will continue taking my insulin if I experience nausea and vomiting." The nurse should teach the client to continue to take her insulin as prescribed during illness to prevent hypoglycemic and hyperglycemic episodes.

A school nurse is providing teaching to an adolescent about levonorgestrel contraception. Which of the following information should the nurse include in the teaching?

Answer: "You should take the medication within 72 hours following unprotected sexual intercourse." A. "You should take the medication within 72 hours following unprotected sexual intercourse." Levonorgestrel is an emergency contraceptive which inhibits ovulation to prevent conception. The nurse should instruct the adolescent to take this medication as soon as possible within 72 hr after unprotected sexual intercourse.

A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV. Which of the following actions should the nurse take?

Answer: The nurse should have calcium gluconate readily available B. Have calcium gluconate readily available. The nurse should have calcium gluconate readily available to prevent cardiac or respiratory arrest in the event the client experiences magnesium toxicity.

A nurse is assessing a client who gave birth vaginally 12 hr ago and palpates their uterus to the right above the umbilicus. Which of the following interventions should the nurse perform?

Assist the client to empty their bladder. Rationale: The nurse should assist the client to empty their bladder because the assessment findings indicate that the client's bladder is distended. This can prevent the uterus from contracting, resulting in increased vaginal bleeding or postpartum hemorrhage.

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?

Begin FHR monitoring

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?

Blood pressure 105/64 mm Hg Rationale: The nurse should report decreased blood pressure to the provider since it can indicate dehydration. Other considerations: Testing the urine for ketones is the most important laboratory test for a client who has hyperemesis gravidarum. Urine testing positive for ketones is an indication of dehydration, which increases the risk of preterm labor. A negative test result is an expected finding. Therefore, the nurse does not need to report this finding to the provider.

The nurse is reviewing laboratory results in the adolescence medical record. The nurse suspects the adolescent is experiencing pelvic inflammatory disease and is planning care. Which of the following prescriptions should the nurse expect the provider to prescribe?

Ceftriaxone and doxycycline

A nurse came for a newborn who is 70 hours old. Which of the findings should the nurse report provider? Select all that apply

Central nervous system findings gastrointestinal findings

A nurse is assessing a newborn following a circumcision. Which of the following findings should the nurse identify as an indication that the newborn is experiencing pain?

Chin quivering

A nurse in a family planning clinic is caring for a client who requests an oral contraceptive. Which of the following findings in the client's history should the nurse recognize as a contraindication to oral contraceptives? (Select all that apply.)

Cholecystitis Hypertension Migraine Headaches

A nurse is coming for a newborn 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.

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.

The nurse is reviewing the provider's prescriptions in the adolescent's medical chart. The nurse should first implement

Education on medication Administration of ceftriaxone

A nurse in the antepartum clinic is assessing a client's adaptation to pregnancy. The client states that they are "happy one minute and crying the next." The nurse should interpret the client's statement as an indication of which of the following?

Emotional lability Rationale: The nurse should recognize and interpret the client's statement as an indication of emotional lability. Many clients experience rapid and unpredictable changes in mood during pregnancy. Intense hormonal changes may be responsible for mood changes that occur during pregnancy. Tears and anger alternate with feelings of joy or cheerfulness for little or no reason.

A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take prior to leaving the newborn with their parent?

Ensure that the parent's identification band number matches the newborn's identification band number. Rationale: The nurse should verify the newborn's identity every time the newborn is returned to the parents. The nurse should match the number on the parent's identification band to the number on the newborn's identification band.

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?

FHR 152/min

A nurse is caring for a client who is at 10 weeks of gestation. Which of the following findings should the nurse report to the provider?

Frequent vomiting with weight loss of 3 lb in 1 week Rationale: The nurse should recognize that frequent vomiting with a weight loss of 3 lb in 1 week may indicate hyperemesis gravidarum and should be reported to the provider. The client could experience electrolyte imbalances due to hyperemesis gravidarum. Common findings during the first trimester of pregnancy: - emotional lability and mood swings - Nosebleeds occurring approximately 3 times per week. (epistaxis) - increased vaginal discharge, or leukorrhea

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.)

Fundal Height Measurement

A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider. Which of the following manifestations should the nurse include?

Headaches that is unresolved by analgesics

A nurse on an antepartum unit is caring for a client. Which of the following nursing actions should the nurse plan to take? For each potential nursing action, click to specify if the intervention is indicated or contraindicated for the client.

Indicated: insert a large bore intervenous catheter and weigh pads Contraindicated : assess cervical dilation and administer methotrexate

A nurse is planning care for a client who is to undergo a nonstress test. Which of the following actions should the nurse include in the plan of care?

Instruct the client to press the provided button each time fetal movement is detected

A nurse is caring for a client who is to receive oxytocin to augment their labor. Which of the following findings contraindicates the initiation of the oxytocin infusion and should be reported to the provider?

Late decelerations Rationale: Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a contraindication for the administration of oxytocin and should be reported to the provider. Other considerations: - Cessation of uterine dilation and a prolonged active phase of labor are indications for the initiation of an oxytocin infusion to augment the client's labor progression. - Moderate variability of the FHR is an expected assessment finding associated with normal fetal acid-base balance. It is not a contraindication to the administration of oxytocin.

A nurse is observing a new guardian caring for their crying newborn who is bottle feeding. Which of the following actions by the guardian should the nurse recognize as a positive parenting behavior?

Lays the newborn across their lap and gently sways Rationale: This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of security for the newborn. Other considerations: - The guardian should place the infant in the supine position, not a prone position, in the bassinet or crib because of the risk of sudden infant death syndrome. - Rice cereal should not be added to the bottle of a newborn because solids should not be introduced until 4 to 6 months of age. - Pacifiers may be used for a newborn who needs extra sucking for self-soothing. However, formula should not be placed on the tip of the pacifier because the newborn might become accustomed to it and refuse to take the pacifier in the future without added supplement.

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation. Which of the following findings should the nurse report to the provider as a potential complication?

Leakage of fluid from the vagina

A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in their left calf. Which of the following actions should the nurse take?

Maintain the client on bedrest

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

A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control. Which of the following actions should the nurse include in the plan of care?

Monitor the client's blood pressure every 5 min following the first dose of anesthetic solution.

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?

Perform Leopold Maneuvers

For each assessment finding, click to specify if the finding is consistent with hypoglycemia, hyperbilirubinemia, or sepsis Each finding may support more than one disease process.

Poor Feeding: Hypoglycemia, Hyperbilirubinemia, Sepsis Decreased Temp: Hypoglycemia, Sepsis Respiratory Distress: Hypoglycemia, Sepsis Ecchymotic caput succedaneum: Hyperbilirubinemia Yellow sclera and oral mucosa: Hyperbilirubinemia, Sepsis Lethargy: Hypoglycemia, Sepsis

A nurse is came for a new one who is 48 hours old. Complete the diagram by dragging from the choices below to specify what condition the client most likely experiencing, two actions and they should take to address the conditions, and two parameters, and Nurse should monitor to assist the client progress

Primary condition: cold stress Action: skin to skin and breastfeeding Monitor; temp and glucose

A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?

Report the client's condition to the local health department

A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?

Substernal retraction

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?

Swelling of the face

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?

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 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

A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?

jaundice

A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?

respiratory distress

A nurse is planning care for a client who is in labor and is to have an amniotomy. Which of the following assessments should the nurse identify as the priority?

temperature