Cindy Mason
The nurse obtains Cindy's vital signs: blood pressure 138/88 mm Hg, pulse 94/min, respiratory rate 20/min, oxygen saturation 99%, temperature 36.6° C (97.9° F). The nurse reviews the EFM strip and notes that the FHR baseline is 130/min with moderate variability and accelerations are present. Contractions are occurring every 4 minutes, lasting 60 to 70 seconds. The nurse notes that Cindy is grimacing with contractions and using slow, deep breathing. Which of the following actions should the nurse take next? Select all that apply.
Bp in 30 Vaginal exam Nitrazine test Educate
Cindy gives birth after 20 minutes of pushing. The placenta is expulsed 6 minutes after the birth. There are no perineal lacerations per the provider's report. There is a moderate amount of lochia rubra without clots and the perineum is mildly edematous. The newborn is on the client's chest for skin-to-skin contact. Which of the following actions should the nurse take? Select all that apply.
Clean peri Ice pack Infuse oxytocin VS q15m Monitor fundus toxicity
Cindy Mason and her partner came in about 5 minutes ago because she thinks she may be in labor. She is a 28-year-old G2P1 who is at 40 weeks of gestation. She had a spontaneous vaginal delivery without complications 3 years ago and this pregnancy has been unremarkable. She reports her contractions began about 4 hours ago and are occurring every 4 to 5 minutes, lasting about 60 seconds. She rates the pain with contractions a 4 on a 0 to 10 pain scale. Cindy also states that her membranes might have ruptured as she has noticed a small amount of fluid on her underwear over the past couple of hours, but that it may also be urine. She appears somewhat anxious and stated that she wasn't sure if she should have come to the hospital or not. The nurse applied the external fetal monitor before coming to the nurse's station to give the report, so Cindy still needs to be assessed. The nurse should identify this client has or is
Client education Pain
The nurse performs a vaginal exam and finds the cervix to be dilated 5 cm, 90% effaced, and vertex presentation at 0 station. There is a small amount of bloody show on the nurse's exam glove and clear fluid noted on the bed pad. The nurse performs a nitrazine test, which is positive. The nurse prepares to notify the provider of the findings. Which of the following provider prescriptions should the nurse anticipate? Select all that apply.
Admin to L&D Intermittent EFM Fentanyl CBC VS q30m Saline lock Epidural per request
Two hours later, Cindy's labor is continuing to progress. She has been ambulating in her room and took a warm shower to assist with pain management during contractions. She is also using the birthing ball intermittently and her partner remains supportive. Her vital signs are blood pressure 126/82 mm Hg, pulse 92/min, respiratory rate 20/min, oxygen saturation 98%, and temperature 37°C (98.6°F). Her cervix is now dilated 8 cm, 100% effaced, and 0 station. The EFM shows a baseline FHR of 128/min, with moderate variability, accelerations are present. Contractions are strong to palpation and occurring every 3 minutes, lasting 70 to 80 seconds. The client is reporting an increase in lower back pain with contractions, rating the back pain an 8 on a 0 to 10 pain scale. She also reports nausea during contractions and is no longer consuming liquids. She voided a small amount of yellow urine about 90 minutes ago. Which of t
Counter pressure Warm compress Hands and knees Infuse LR
Maslow's Hierarchy of Needs
High
Safety
High
Urgent
High
Chronic / Stable
Love
ABC
Low
Can I get some medication to help with this gas?
Request lvn
Half an hour later, Cindy reports an urge to push with contractions. The nurse performs a vaginal exam and finds the cervix dilated 10 cm, 100% effaced, +2 station. The client's vital signs are blood pressure 129/88 mm Hg, pulse 104/min, respiratory rate 22/min, and oxygen saturation 99%. The EFM shows a baseline FHR of 128/min, with moderate variability. The provider arrives to assess Cindy's progress and the nurse provides a report of the current findings. Which of the following actions should the nurse plan to take? Select all that apply.
VS q15m Cloth to forehead Deep breath p contraction
