A nurse is caring for a client diagnosed with acute rhinosinusitis.

Which of the following instructions should the nurse provide to the client? Select all that apply. 

An adolescent client who has successfully managed hemophilia for the past 10 years is evaluated by the nurse.
Which behavior best evidences the client’s adjustment to the disorder as an adolescent?

A newborn’s assessment reveals spina bifida occulta.
Which maternal factor should the nurse identify as having the greatest impact on the development of this newborn complication?

A client’s maternal serum alpha-fetoprotein level is elevated at 17 weeks.
What condition should the nurse identify as the likely cause of this increase?

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

The nurse is evaluating the growth and development of a 3-year-old child.
Which speech and language skills should the nurse identify as normal developmental milestones for this child?

The nurse receives 2 newborns within the first minutes after a vaginal delivery and intervenes to establish adequate respirations.
What is the priority issue that the nurse should address to ensure the newborn’s survival?

A 17-year-old student arrives at the emergency department (ED) complaining of severe abdominal pain and cramping that has worsened since the morning.

Her mother suspects a urinary tract infection due to her daughter’s frequent and urgent urination, or possibly appendicitis.

What signs would indicate that a healthy psychosocial adaptation is taking place? Select all that apply.

A patient was received one hour after delivering a 9 lb 1 oz (4.1 kg) female baby.

Her vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.

She was assisted to the bathroom where she voided 150 mL of clear yellow urine.

Lochia rubra is moderate with small clots, no foul odor noted.

The fundus is firm at the umbilicus.

The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis.

There is no pain, redness, or swelling in the calves.

A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag.

The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.

A woman is in the second stage of labor where the fetal head has just been born and the nurse observes the immediate retraction of the head against the perineum.
What action should the nurse expect to perform to assist the healthcare provider?