The nurse is assessing four clients on the postpartum unit. Each client's uterine assessment is below. 1. The client is three days postpartum and her fundus is 3 cm below the umbilicus 2. The client is two days postpartum and her fundus is 2 cm above the umbilicus 3. The client is one day postpartum and her fundus is 1 cm below the umbilicus 4. The client delivered 8 hours ago and her fundus is at the umbilicus

Which client is experiencing uterine subinvolution?

IV calculations: (rate-mL/h and gtt/min)

• IV rate calculations will be rounded to nearest whole number.

Adult calculations: the calculation will be rounded to the nearest tenth. Drug Calculation safety considerations:

• Examples:
  • 5 must be answered as 0.5
  • 5.0 must be answered as 5
• To promote safety, a zero must be placed to the left of the decimal point in answers that are less than one. No zero is allowed to the right of the decimal point in answers that are whole numbers.
• Labeling is not necessary

Available: see drug label above Ordered promethazine 12.5mg IM

How many mL of promethazine will the nurse administer?

The nurse is caring for a multiparous client who has been in labor for 12 hours. The client had a spontaneous vaginal delivery 2 years ago. This was an unplanned pregnancy with someone she only knew briefly. Since finding out she was pregnant, she has been alone. Her pain is now 8/10 and she is becoming fearful that something is wrong since she has been in labor so long.

Contractions assessment:

• Contractions every 3-4 minutes
• Palpating moderate in intensity
• Lasting 45-60 seconds Cervical exam: .3 cm
• 90% effaced . -2 station
• Fetus is in a cephalic presentation.

Which component of labor is keeping the client from advancing in labor?

The nurse is caring for a client in labor. Assessment findings: The fetal heart rate (FHR) baseline is 120 bpm The FHR begins slowing as the contraction starts, and is back to baseline at the end of the contraction There is moderate variability of the FHR Which periodic change will the nurse document in the electronic health record?

The nurse assesses the postpartum client's fundal height and tone in the first 24 hours. Which action will the nurse take to correctly assess the uterine fundus?

The nurse is caring for a client in labor. Which process will the nurse use to determine the duration of contractions?

A nurse is planning home care for a 9-year-old child following an acute exacerbation of asthma. Which of the following of Erikson’s developmental stages should the nurse consider in the planning?

The nurse assesses a laboring client's cervix and states it is 6 cm dilated and 70% effaced.
The client asks what it means to be effaced. Which descriptions will the nurse include when responding to the client? Select all that apply.

The nurse is discussing birth options with a pregnant client. The client previously had a cesarean birth with a classical incision at 26 weeks' gestation but desires a vaginal birth with this pregnancy. What is the best response by the nurse?

The nurse notices a decreased fetal heart rate (FHR) on the fetal monitor tracing and contacts the charge nurse. The charge nurse completes a vaginal exam and can feel a portion of the umbilical cord in the vagina.

Which emergency interventions will the charge nurse implement? Select all that apply.

The nurse is admitting a client in the first stage of labor with active genital herpes. Which type of birth will the nurse anticipate for this client?