1. 16. A nurse is caring for a newborn who is 4 hr old.

   Nurses' Notes

   Large ecchymotic caput succedaneum noted on occiput with molding of the skull. Anterior fontanel level and soft.
   Newborn's respirations are shallow and irregular.

   Newborn's skin color is consistent with their genetic background. Acrocyanosis noted. The newborn is active and moves all extremities except for left arm. Left arm remains at side during Moro reflex. Bilateral gluteal folds equal. Base of spine closed.
   Breastfed vigorously for 30 min.

   Drag 1 condition and 1 client finding to fill in each blank in the following sentence.
   
   The newborn most likely has as evidenced by Condition a clavicle fracture neonatal abstinence syndrome (NAS) developmental dysplasia of the hip (DDH) a subgaleal hemorrhage a congenital cardiac defect

A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." Which of the following should the nurse recognize as a sign of true labor?

A nurse is assessing a client who is in active labor and notes that the presenting part is at 0 station. Which of the following is the correct interpretation of this clinical finding?

A nurse is caring for a client who has just delivered a newborn. The nurse notes secretions bubbling out of the newborn's nose and mouth. Which of the following actions is the nurse's priority?

A nurse is caring for a client who just delivered a newborn. Following the delivery, which nursing action should be done first to care for the newborn?

A nurse is assessing a client in labor who has had epidural anesthesia for pain relief. Which of the following findings should the nurse identify as a complication from the epidural block?

A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider? 

A nurse is caring for a client who is 2 hr postpartum following a vaginal birth. Which of the following findings indicates the client's bladder is distended?

A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?

A nurse is assessing a newborn. Which of the following should the nurse understand is a clinical manifestation of pyloric stenosis?

51. A nurse in an antepartum clinic is caring for a client who is pregnant.

Medical History 0815:

Gravida 4 Para 3

33 weeks of gestation Allergies: Sulfa Height 165 cm (66 in)
Weight 82 kg (180 lb)

BMI 30.6

3.2 kg (7 lb) weight gain over the last 2 weeks

Select the 4 assessment findings the nurse should report to the provider.