Maternity OB Pt2

A nurse is caring for a client who is 38 weeks gestation and has been diagnosed with chorioamnionitis. Which of the following nursing interventions is a priority?

Administer oxytocin

A patient suddenly begins having difficulty breathing, becomes confused, and is hypotensive. The nurse suspects what condition?

Amniotic fluid embolism

A nurse is caring for a client who is at 34 weeks of gestation and has a suspected placenta previa. Which of the following actions should the nurse take?

Apply an external fetal monitor.

A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery. Which of the following actions should the nurse take?

Apply an ice pack to the perineum.

A client who has just given birth to a healthy newborn required an episiotomy. Which action would the nurse implement immediately after birth to decrease the client's pain from the procedure?

Apply an ice pack to the site.

A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F), pulse rate 88./min, respiratory rate 18/min. Which of the following actions should the nurse perform?

Ask the client to empty her bladder. Rationale: Whenever the fundus is deviated from the midline, a full bladder should be considered as a potential cause. A full bladder could result in complications such as uterine atony or infection.

During a vaginal delivery, the physician states that a shoulder dystocia is occurring. Which intervention may be expected of the nurse?

Assist the client to flex her thighs upon her abdomen. Rationale: McRobert's manoeuvre - hyperflex maternal hips (knees to chest position) and tell the patient to stop pushing. This widens the pelvic outlet by flattening the sacral promontory and increasing the lumbosacral angle. This single manoeuvre has a success rate of about 90% and is even higher when combined with 'suprapubic pressure',

​A nurse is collecting data from a client who is 12 hr postpartum following a spontaneous vaginal delivery. The nurse should expect to find the uterine fundus at which of the following positions on the client's abdomen?

At the level of the umbilicus

A nurse is caring for a client who is experiencing shaking chills during the immediate postpartum period. Which of the following actions should the nurse take?

Cover the client with warm blankets

A nurse is caring for a client who is pregnant and undergoing a non-stress test. The nurse records the FHR as 130 to 150/min, with no fetal movement for 15 min. Which of the following actions should the nurse take?

Encourage the client to walk around and then resume monitoring Rationale: This action will not stimulate a fetal response.

​A nurse is collecting data from a client who is 3 days postpartum and is breastfeeding. Her fundus is three fingerbreadths below the umbilicus, and her lochia rubra is moderate. Her breasts feel hard and warm. Which of the following recommendations should the nurse give the client?

Express milk from both breasts. Rationale: For this postpartum day, the client's fundal location and lochia characteristics are within the expected reference range. The client's manifestations indicate that she is experiencing breast engorgement, an expected finding, as this is the time when the milk "comes in." Frequent breastfeeding and expressing milk from the breasts can help relieve engorgement.

A nurse is caring for a client who is 12 hr postpartum. The nurse recognizes the client is in the dependent, taking-in phase of maternal postpartum adjustment. Which of the following is an expected finding during this period?

Expressions of excitement

​A nurse is reinforcing teaching with a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse recognizes that which of the following is the most common risk factor for a placental abruption?

Maternal hypertension

A nurse is reviewing the medical record of a client who experienced a vaginal birth 2 hr ago. The nurse should identify that which of the following findings places the client at risk for a postpartum hemorrhage?

Precipitous birth

A nurse is assisting with the admission of a client who is at 39 weeks of gestation and has heavy vaginal bleeding. Which of the following actions should the nurse take immediately?

Prepare for cesarean birth. Rationale: The nurse should begin preparing for a cesarean birth for a client who is full term and has heavy vaginal bleeding. A client who has heavy vaginal bleeding is at risk for hemorrhage and subsequent fetal compromise. Therefore, immediate delivery via cesarean section will likely be advised.

A nurse is assisting with the care of a client who is at 37 weeks of gestation and has placenta previa. Which of the following risks is the primary reason the nurse should avoid performing a pelvic examination?

Profound bleeding

A pregnant client is brought to the health care facility with signs of premature rupture of membranes. Which conditions and complications are associated with PROM?

Prolapsed cord Abruptio placenta Spontaneous abortion Preterm labor Infection Rationale: The associated conditions and complications of premature rupture of the membranes are infection, prolapsed cord, abruptio placenta, and preterm labor. Spontaneous abortion and placenta previa are not associated conditions or complications of premature rupture of membranes.

A nurse is assisting with the care of a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion?

Respiratory rate of 16/min Rationale: The client's respiratory rate should be at least 12/min as a precaution against excessive depression of impulses at the myoneural junction. Based on this finding, the nurse can continue the infusion.

​A nurse is preparing to auscultate fetal heart tones for a client who is pregnant. Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundal portion of the uterus and a long, smooth surface on the mother's right side. In which of the following maternal quadrants should the nurse auscultate fetal heart tones?

Right upper quadrant

A nurse is preparing a sitz bath for a client who is 1 day postpartum. Which of the following actions should the nurse take?

Set the water temperature to 40° C (104° F).

A nurse is reinforcing discharge teaching with a client who is 2 days postpartum and has a history of postpartum depression. Which of the following instructions should the nurse include?

Sleep as much as possible.

A nurse is caring for a client who is postpartum. Which of the following findings is an indication for the nurse to administer Rho(D) immune globulin?

The client is Rh negative and the newborn is Rh positive. Rationale: Rho(D) immune globulin contains antibodies to Rho(D). Administering it prevents antibody formation in clients who are Rh-negative following exposure to Rh-positive blood, such as in a fetus who is Rh-positive.

A 36-week pregnant client presents to the OB department for a scheduled external cephalic version. The nurse understand the potential complications of an external cephalic version include: (Select all that apply).

Twisting of the umbilical cord Placenta abruptio Brachial plexus injury Rupture of amniotic membranes Rationale: Potential risks of version, for which the fetus and mother are closely monitored, include: Twisting or squeezing of the umbilical cordLinks to an external site., reducing blood flow and oxygen to the fetus. The beginning of labor, which can be caused by rupture of the amniotic sac around the fetus (premature rupture of the membranes, or PROM). Placenta abruptio, rupture of the uterus, or damage to the umbilical cord. The potential exists for such complications, but they are very rare.

A nurse is caring for a postpartum client following a vaginal birth of a newborn weighing 4252 g (9 lb 6 oz). The nurse should identify that this client is at risk for which of the following postpartum complications?

Uterine atony

A nurse is caring for a client who is at 28 weeks of gestation and has received terbutaline. Which of the following findings should the nurse expect?

Weakened uterine contractions Rationale: Terbutaline is a beta2-adrenergic agonist that acts to relax the uterus. Terbutaline is used to stop a contraction pattern in a client who is at preterm gestation.

A nurse is reviewing information about maternal and paternal adaptations to the birth of a newborn. The nurse observes the parents interacting with their newborn physically and emotionally. The nurse documents this as:

attachment.

The nurse is making a follow-up home visit to a woman who is 12 days postpartum. Which finding would the nurse expect when assessing the client's fundus?

cannot be palpated

On a follow up visit to the clinic, a nurse suspects that a postpartum client is experiencing postpartum psychosis. Which finding would most likely lead the nurse to suspect this condition?

delusional beliefs

A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would question the woman about which symptom?

hardening of an area in the affected breast.

A nurse is reviewing the policies of a facility related to bonding and attachment with newborns. Which practice would the nurse identify as needing to be changed?

offering around-the-clock nursery care for all infants

A nurse is teaching a new mother about breast-feeding. The nurse determines that the teaching was successful when the woman identifies which hormone as responsible for milk let-down?

oxytocin

A nurse is visiting a postpartum woman who delivered a healthy newborn 5 days ago. Which finding would the nurse expect?

pinkish brown discharge

A postpartum woman is having difficulty voiding for the first time after giving birth. Which action would be least effective in helping to stimulate voiding?

placing her hand in a basin of cool water.

The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which action would be a priority?

placing the call light within her reach prior to leaving the bathroom.

A nurse is assessing a postpartum woman. Which finding would lead the nurse to suspect that a postpartum woman is having a problem?

pulse rate of 110 beats/minute

A postpartum client comes to the clinic for her 6-week postpartum check-up. When assessing the client's cervix, the nurse would expect the external cervical os to appear:

slit-like

Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which condition?

thrombophlebitis

A primipara client gave birth vaginally to a healthy newborn girl 48 hours ago. The nurse palpates the client's fundus and documents which finding as normal?

two fingerbreadths below the umbilicus.

A nurse is reinforcing teaching about Kegel exercises with a client who is two days postpartum.. Which of the following statements by the client indicates an understanding of the teaching?

​"These exercises will help my pelvic muscles stretch when I give birth."

A nurse is assisting in the care of a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse take?

​Encourage the client to empty the bladder every 2 hr.

A nurse is assisting with the care of a client who is in labor. The client's labor is difficult and prolonged and she reports a severe backache. Which of the following factors is a contributing cause of difficult, prolonged labor?

​Fetal position is persistent occiput posterior. Rationale: The persistent occiput posterior position of the fetus is a common cause of prolonged, difficult labor with severe back pain.

The nurse administers Rho(D) immune globulin to an Rh-negative client after delivery of an Rh-positive newborn based on the understanding that this drug will prevent her from:

developing Rh sensitivity.

A nurse is reinforcing teaching about comfort measures for breast engorgement with a client who is postpartum and is bottle feeding her newborn. Which of the following statements by the client indicates a need for further teaching?

"I should stimulate my nipples by squeezing softly."

A postpartum client who is bottle feeding her newborn asks, "When should my period return?" Which response by the nurse would be the most appropriate?

"It varies, but you can estimate it returning in about 7 to 9 weeks."

A postpartum client has a fourth-degree perineal laceration. The nurse would expect which medication to be ordered?

ducosate

A client who is breast-feeding her newborn tells the nurse, "I notice that when I feed him, I feel fairly strong contraction-like pain. Labor is over. Why am I having contractions now?" Which response by the nurse would be most appropriate?

"The baby's sucking releases a hormone that causes the uterus to contract."

A primigravida is admitted to the labor and delivery unit. Her membranes have ruptured, she is 1 cm dilated, 20% effaced, and is not having contractions. She asks the nurse, "Do I get the epidural now? I really don't want any pain." The best response by the nurse is: (Select all that apply).

"What can I do to help you relax?" "I can help you cope with the pain until the epidural is started." "We can't give the epidural until you are well established in labor or it may slow your labor."

A nurse is reinforcing teaching about signs preceding the onset of labor with a client who is at 39 weeks of gestation. Which of the following statements should the nurse include?

"You will experience a surge of energy."

A woman who gave birth 24 hours ago tells the nurse, "I've been urinating so much over the past several hours." Which response by the nurse would be most appropriate?

"Your body is undergoing many changes that cause your bladder to fill quickly."

A nurse is making a home visit to a postpartum woman who delivered a healthy newborn 4 days ago. The woman's breasts are swollen, hard, and tender to the touch. The nurse documents this finding as:

engorgement.

A woman who delivered a healthy newborn several hours ago asks the nurse, "Why am I perspiring so much?" The nurse integrates knowledge that a decrease in which hormone plays a role in this occurrence?

estrogen

After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention?

frequent, scant voidings.

The nurse is caring for a client after experiencing a placental abruption, Which findings the priority to report to the healthcare provider?

45mL urine output in 2 hours

A nurse is assisting with the care of a client who is using pattern-paced breathing during the first stage of labor. The client says she feels lightheaded and her fingers are tingling. Which of the following actions should the nurse take?

Assist the client to breathe into a paper bag.

A nurse is caring for a group of clients on an intrapartum unit. Which of the following findings should be reported to the RN immediately?

A client who has preeclampsia and reports epigastric pain and unresolved headache

A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa. For which of the following findings should the nurse monitor the client?

A large amount of bright red vaginal bleeding without pain Rationale: With placenta previa, the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os, or outlet to the vagina. Clients who have placenta previa have sudden, painless vaginal bleeding, typically in the third trimester.

The nurse is caring for a client experiencing a prolonged second stage of labor. The nurse would place a priority on preparing the client for which intervention?

Assisted delivery with forceps and/or vacuum

A nurse is assisting with monitoring a client in labor who has preeclampsia and is receiving magnesium sulfate. The client's respiratory rate is 8/min. Which of the following should the nurse administer?

Calcium gluconate Rationale: The nurse should plan to administer calcium gluconate or calcium chloride as the reversal agent for a client who experiences magnesium sulfate toxicity.

A nurse is reinforcing teaching with a client who is in labor about why epidural anesthesia is not initiated until a good labor pattern has been established. Which of the following explanations should the nurse include?

Given too soon, epidural anesthesia can prolong labor. Rationale: Progress in labor slows when clients are given anesthesia before the active phase of labor. The medication depresses the central nervous system, thus it will take longer for the cervix to dilate and efface.

A nurse is caring for a client who is 1 day postpartum following a cesarean birth. To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client's plan of care?

Have the client ambulate frequently in the hallway.

A nurse is assisting with the care of a client who is multigravid and in active labor with 7 cm of cervical dilation and 100% effacement. The fetus is at 1+ station, and the client's amniotic membranes are intact. The client suddenly states that she needs to push. Which of the following is the appropriate nursing response?

Have the client pant during the next few contractions.

A nurse is assisting with the care of a client who had an epidural anesthesia block during the early stages of labor. The client's blood pressure is 80/40 mm Hg and the fetal heart recording is 140/min. Which of the following actions should the nurse take first?

Place the client in a lateral position. Rationale: The nurse should first turn the client laterally to relieve the pressure on the inferior vena cava and improve the blood pressure.

A nurse is assisting in the care of a client who is in active labor. The nurse notes late decelerations on the fetal monitor tracing. Which of the following actions should the nurse take first?

Position the client on her side

A nurse is assisting with the care of a client who is in labor and has the urge to push. Which of the following instructions should the nurse give the client?

Take a deep, cleansing breath before and after each contraction

A nurse is assisting in the care of a client who is in labor. The doctor documents the vaginal examination as: 3 cm, 30%, and -1. The nurse evaluates this documentation to mean which of the following?

The cervix is dilated 3 cm, it is effaced 30%, and the presenting part is 1 cm above the ischial spines. Rationale: ​Dilation of the cervix is measured from closed to 10 cm; effacement, or thinning and shortening of the cervix, is measured from 0% to 100%; and station is the relation of the presenting part to the ischial spines of the maternal pelvis and is measured in centimeters above, below, or at the level of the spines. If the station is -1, then the presenting part is 1 cm above the ischial spine.

A nurse is reinforcing teaching with a newly licensed nurse about a biophysical profile. Which of the following information should the nurse include in the teaching?

The test predicts fetal well-being in the third trimester Rationale: The biophysical profile is used to predict fetal well-being in the third trimester of pregnancy. A biophysical profile consists of a nonstress test combined with a detailed ultrasound. The ultrasound measures four markers: amniotic fluid volume, fetal breathing movements, gross fetal movement, and fetal tone.

A nurse is assisting in the care of a client who is in active labor. The nurse notes variable decelerations of the FHR. The nurse should identify which of the following as a cause of variable decelerations?

Umbilical cord compression Rationale: The nurse should identify that variable decelerations are caused by compression of the umbilical cord.

Assessment of a postpartum client reveals a firm uterus with bright-red bleeding and a localized bluish bulging area just under the skin at the perineum. The woman also is complaining of significant pelvic pain and is experiencing problems with voiding. The nurse suspects which condition?

hematoma.

A nurse is teaching a postpartum client how to do muscle-clenching exercises for the perineum. The client asks the nurse, "Why do I need to do these exercises?" Which reason would the nurse most likely incorporate into the response?

improves pelvic floor tone

A nurse is assisting with the care of a client who is in labor. Which of the following findings should the nurse report to the provider?

Fetal heart rate 100/min for a 10-min period Rationale: A fetal heart rate of 100/min for a 10-min period is bradycardia. Therefore, the nurse should notify the provider of this finding.

A nurse is admitting a client who is 42 weeks gestation to the health care facility. The client is suspected of having cephalopelvic disproportion (CPD). Which should the nurse do next?

Prepare the client for a cesarean birth. Rationale: Cephalopelvic disproportion is associated with post-term pregnancy. This client will not be able to vaginally deliver and should be prepared for a cesarean birth. Lithotomy position, AROM (artificial rupture of membranes, and oxytocin are indicated for a vaginal birth.

A nurse is caring for a client who is at 38 weeks of gestation and has a positive contraction stress test. Which of the following actions should the nurse take?

Prepare the client for admission to the hospital.

A nurse is assisting with the care of a client who presents to a labor and delivery unit with rapidly progressing labor. Which of the following actions is the priority for the nurse to take?

Preventing the perineum from tearing

A nurse is caring for a client during a nonstress test (NST). The nurse observes two decelerations of 15/min in the fetal heart rate during a period of fetal movement. Each deceleration lasts 20 seconds. Which of the following results are indicated by these findings?

A nonreactive test

A nurse is assisting with the care of a client who is in early labor with intact membranes and a temperature of 38.9° C (102° F). After notifying the provider, which of the following actions should the nurse take?

Administer acetaminophen orally. Rationale: The nurse should monitor the client's temperature every 30 to 60 min since the client is febrile. For a client who is afebrile, the nurse should monitor the temperature every 2 to 4 hr during labor if the amniotic membranes are intact, and then every 2 hr after they rupture.

A nurse is reinforcing teaching with a client who is scheduled for a nonstress test (NST). Which of the following information should the nurse include?

An external fetal monitor will be used to monitor the FHR. Rationale: During a nonstress test, the client is seated in a semi-reclining position. An external fetal monitor is applied to detect the FHR and uterine contractions. The FHR is monitored for 20 to 30 min. A reactive, or reassuring, FHR is determined to be the presence of two accelerations in a 20-min period, each lasting at least 15 seconds and peaking at least 15 beats/min above the FHR baseline.

A client who is in labor presents with shoulder dystocia of the fetus. Which nursing intervention is a priority when managing care and preparing for delivery?

Assisting in positioning the woman in a squatting position. Rationale: The nurse caring for the client in labor with shoulder dystocia of the fetus should assist with positioning the client in squatting position. The client can also be helped into the hands and knees position or lateral recumbent position for birth to free the shoulders. Assessing for intense back pain in the first stage of labor, anticipating possible use of forceps to rotate the anterior position at birth, and assessing for prolonged second stage of labor with arrest of descent are important interventions when caring for a client with persistent OP (occiput posterior) position of the fetus.

A nurse is assisting a nurse midwife in examining a client who is a primigravida at 42 weeks of gestation and states that she thinks she is in labor. Which of the following findings confirm that the client is in labor?

Cervical dilation

A nurse is collecting data from a postpartum client and finds a large amount of lochia rubra with several clots on the client's perineal pad. Which of the following actions should the nurse take first?

Check the client's fundus. Rationale: The primary cause of excessive postpartum bleeding is uterine atony. The priority action the nurse should take is to check the client's fundus. A boggy fundus requires massage by the nurse. Failure of the uterus to contract with massage warrants further intervention by the nurse, such as having the client empty her bladder.

A nurse is reinforcing teaching about reducing the risk of perineal infection with a client who had a vaginal birth. Which of the following information should the nurse include in the teaching? (Select all that apply.)

Clean the perineal area from front to back. perform hand hygiene before and after voiding. Blot the perineal area dry after voiding.

A nurse on the postpartum unit is collecting data from a client who experienced abruptio placentae. The nurse observes petechiae and bleeding around the IV access site. The nurse should recognize this client is at risk for which of the following postpartum complications?

Disseminated intravascular coagulation (DIC) Rationale: The nurse should recognize that experiencing abruptio placentae places the client at higher risk for DIC. Clinical manifestations of DIC include oozing from intravenous access and venipuncture sites; petechiae, especially under the site of the blood pressure cuff; spontaneous bleeding from the gums and nose; other signs of bruising; and hematuria.

A woman who is 12 hours postpartum had a pulse rate around 80 beats per minute during pregnancy. Now, the nurse finds a pulse of 66 beats per minute. Which of these actions should the nurse take?

Document the finding, as it is a normal finding at this time.

A nurse is collecting data from a client who is postpartum 2 hr following delivery of a healthy newborn. Which of the following findings indicates the client's bladder is distended?

Elevated fundus level

A nurse is monitoring a client with premature rupture of membranes (PROM) who is in labor and observes meconium in the amniotic fluid. What does this indicate?

Fetal distress related to hypoxia Rationale: When meconium is present in the amniotic fluid, it typically indicates fetal distress related to hypoxia. Meconium stains the fluid yellow to greenish-brown, depending on the amount present. A decreased amount of amniotic fluid reduces the cushioning effect, thereby making cord compression a possibility. A foul odor of amniotic fluid indicates infection.

A nurse is reinforcing teaching about a biophysical profile with a client who is at 40 weeks of gestation. The nurse should explain that this profile focuses on which of the following parameters? (Select all that apply.)

Fetal motion Fetal breathing Amniotic fluid volume Rationale: Fetal movements is correct. A biophysical profile includes evaluation of gross body movements of the fetus. Fetal breathing is correct. A biophysical profile includes evaluation of fetal breathing movements. Amniotic fluid volume is correct. A biophysical profile includes a qualitative evaluation of amniotic fluid volume.

A nurse is assisting with the admission of a client who is at 38 weeks of gestation and has severe preeclampsia. When collecting data from the client, the nurse should expect which of the following findings?

Headache

​A home health care nurse is reinforcing teaching about breast engorgement with a client who is postpartum and is breastfeeding her newborn. Which of the following client statements indicates an understanding of the teaching?

I'll feed my baby every 2 hours."

A nurse in a prenatal client is caring for a client who is at 38 weeks of gestation and has heavy, red vaginal bleeding, without contractions, that started spontaneously. She is in no distress and states that she can "feel the baby moving." The client should undergo an ultrasound to determine which of the following findings?

Location of the placenta Rationale: Painless, spontaneous vaginal bleeding might be an indication of placenta previa. With the ultrasound, the provider can identify the location of the placenta and urgency of the delivery.

A nurse is assisting with the care of a client who is in labor. Which of the following nursing actions reflects application of the gate control theory of pain?

Massaging the client's back

A nurse is reinforcing teaching with a newly licensed nurse about the complications associated with maternal gestational diabetes. Which of the following complications should the nurse include?

Newborn hypoglycemia Rationale: The nurse should identify that hypoglycemia is a common complication for newborns whose mothers have gestational diabetes.

A nurse is assisting in the care of a client who is in the second stage of labor. Which of the following findings should the nurse report to the provider?

Uterine contraction lasting 2 min Rationale: A uterine contraction lasting for more than 90 seconds is a sign of uterine tachysystole, which can lead to uterine rupture. The nurse should report this finding to the provider.

When caring for a mother who has had a cesarean birth, the nurse would expect the client's lochia to be:

less than after a vaginal delivery.

​A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. Which of the following measures should the nurse suggest to help lessen discomfort during breastfeeding? (Select all that apply.)

Apply breast milk to her nipples before each feeding Change the infant's position on the nipples. Alternate breasts at the beginning of each feeding.

A nurse is caring for a client in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina. Which of the following actions should the nurse take first?

Prepare the client for an emergency cesarean birth. Rationale: Placing the client in the knee-chest or Trendelenburg position takes pressure off the umbilical cord to allow oxygen transport to the fetus. This is the priority nursing action until the baby can be delivered either vaginally or by cesarean birth.

A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be alert for which condition in the mother and the newborn?

infection

The nurse is assessing a postpartum client's lochia and finds that there is about a 4-inch stain on the perineal pad. The nurse documents this finding as which description?

light

A postpartum client is experiencing subinvolution. When reviewing the woman's labor and birth history, which contributor would the nurse identify as being significant to this condition?

long duration of labor.

A nurse is collecting data from a client who gave birth one week ago. Which of the following findings should the nurse identify as a manifestation of endometritis?

​Pelvic pain Rationale: Manifestations of endometritis, the most common postpartum infection, include chills, fever, tachycardia, anorexia, fatigue, and pelvic pain.

A nurse is caring for a client who is at 38 weeks of gestation who has a score of 10 on her biophysical profile (BPP). Which of the following actions should the nurse take?

Assure the client that the score is within the expected range. Rationale: The biophysical profile yields a score based on fetal breathing, movement, tone, amniotic fluid volume, and fetal heart rate reactivity. A score of 2 is assigned to each expected finding. A score of 10 indicates expected findings in all five areas.