The nurse continues caring for the client:
The client is a 26-year-old female who was in a car accident 6 months s ago that killed her mother, husband, and 2-year-old son. She and her father were the only survivors of the crash. She is seeking care for depression.
Click to indicate whether findings at the next follow-up appointment indicate that the treatment was effective or ineffective. Each row must have one response selected.

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?

1. A nurse is caring for a newborn who is 30 min old.

Nurses' Notes

1030:

Newborn placed on the birth parent's abdomen immediately following birth. Mouth and nose suctioned with bulb syringe. Dried and stimulated. Strong cry noted. Moving all extremities. Flexed tone noted. Acrocyanosis present.

1100:

Newborn is alert and active. Respirations rapid and shallow with occasional expiratory grunting, Fine crackles auscultated throughout lung fields. Small amount of green-stained vernix present in skin folds. Fingernails stained green. Molding of skull and generalized soft occipital swelling noted. Vital Signs

1030:

Axillary temperature 36.9° C (98.4° F)

Heart rate 170/min Respiratory rate 72/min

1100:

Birth weight 4,025 gm (8 lb 14 oz) (Appropriate for Gestational Age) Axillary temperature 36.7° C (97.8° F)

Heart rate 162/min Respiratory rate 80/min

After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? The condition that poses the

greatest risk to the newborn is meconium aspiration syndrome due to color of amniotic fluid.

Condition meconium aspiration syndrome meconium ileus

cold stress hypoglycemia jaundice Finding color of amniotic fluid birth weight acrocyanosis gestational age

Apgar scores

A nurse is caring for a client who experienced a vaginal birth 3 hr ago. Upon palpation, the fundus is displaced to the right of midline, is firm, and is two fingerbreadths above the umbilicus. Which of the following actions should the nurse complete at this time?

A nurse in a prenatal clinic is caring for a client who is suspected of having a hydatidiform mole. Which of the following findings should the nurse expect to observe in this client?

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 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?

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 postpartum client.

Click to highlight the client statements that indicate an understanding of the discharge teaching.

"Because of my baby's weight loss, I need to supplement with formula after breastfeeding."

"I should make sure that my baby feeds 8 to 12 times per day."

"I should cover my sore nipples with plastic-lined breast pads after every feeding."

"My baby's stools should turn to a yellow color within the next day or two.

I can increase my milk supply by drinking more water.

I should expect my breasts to become harder, warmer, and more tender when my milk comes in."

A nurse is planning care for a newborn who is small for gestational age (SGA). Which of the following is the priority intervention the nurse should include in the newborn's plan of care?

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?