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?

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?

During the second stage of labor, 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 anticipate performing to assist the healthcare provider?

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 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.

What other symptoms is the nurse likely to note in a child diagnosed with epiglottitis?

The nurse is caring for a child who has had a unilateral long-leg cast applied for the correction of club foot.
What is the most important action for the nurse to perform?

A 3-year-old male was brought into the emergency room this morning with a sudden onset of “fast and noisy breathing”. According to his parents, he had sneezing and a runny nose last week but seemed to have recovered.

The child lives with 2 older, school-age siblings, his parents, and 3 dogs.

He was born at 37 weeks’ gestation.

The parents deny smoking, but his grandmother cares for him in the afternoons and smokes outside when she is at the house.

He has no significant medical history.

He has received all vaccines except for those due at 3 years.

Upon exam, the child is… Which two items must the nurse ensure are available before attempting to place the intravenous line?

A client at 38-weeks gestation reports experiencing severe abdominal pain.
Upon palpation, the nurse notes that the abdomen is rigid.
How should the nurse document the findings?

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?