A nurse is providing care for a patient who has recently given birth to her first child. The patient has a history of receiving a transfusion with Rh-negative blood.
The nurse expects hyperbilirubinemia due to Rh incompatibility.
What is the reason for hyperbilirubinemia occurring with Rh incompatibility?

A nurse is caring for a client who is suspected to have an ectopic pregnancy at 8 weeks of gestation. What symptoms should the nurse expect to observe that are consistent with this diagnosis?

A nurse is caring for a client with preeclampsia who is being treated with IV magnesium sulfate. The client’s respiratory rate is 10/min and deep-tendon reflexes are absent.
What action should the nurse take?

A nurse is caring for an infant who is receiving phototherapy. Which of the following findings requires intervention by the nurse?

A nurse is caring for a client who is in the first stage of labor. The nurse observes the umbilical cord protruding from the vagina.

Which of the following actions should the nurse perform first?

A nurse is providing care at a routine visit for a client who is at 36 weeks of gestation.

The client reports a mild headache for the last several days as well as “heartburn”. The client denies visual disturbances, vaginal bleeding, or leakage of fluid from the vagina.

The client reports occasional contractions and positive fetal movement.

The client reports they are unable to remove rings from fingers for the last several days. The client reports feeling dizzy when they got up from the examination table.
Which of the following findings should the nurse report to the provider? (Select all that apply)

A nurse is caring for an adolescent client who has pelvic inflammatory disease due to a sexually transmitted infection and will require intravenous antibiotic therapy.

The client tells the nurse, “My parents think I’m a virgin.

I don’t think I can tell them I have this kind of infection.”. Which of the following responses should the nurse make?

A nurse is caring for a client who is 36 hours postpartum.

The nurse’s notes indicate the following: Breasts are soft, warm, and tender to touch. The client denies any nipple or breast discomfort.

The fundus is boggy, located 1 cm above the umbilicus and deviated to the right. The fundus becomes firm with massage.

The client reports abdominal cramping and rates the pain as 8 on a scale of 0 to 10. The perineal pad shows a moderate amount of lochia rubra.

The client has been given an analgesic.

After reviewing the information in the client’s medical record, which of the following complications poses the greatest risk for the client?

A nurse is caring for a newborn who is 56 hours old.
Vital Signs: At 07:00: Awake, alert, and crying.
The color is pink with acrocyanosis.
The respiratory rate is 70/min with no retractions, grunting, or nasal flaring noted.
Jitteriness is noted in the hands.
At 07:20: Attempted to feed the newborn.
Poor feeding and poor suck were noted.
Loose stool was observed in the diaper, which was then changed.
Which of the following assessment findings is consistent with neonatal abstinence syndrome (NAS)?

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?