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 is assisting a pregnant patient into bed after the patient reports a gush of fluid from the vagina. Which action will the nurse take first?

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

Question

The nurse received report for the client at 1400. The client was given medication through her NG tube at 1800: Ampicillin 20 mL, Pepcid 10 mL, and Reglan 15 mL. After each medication was given, there was a 30 mL flush with water. Her Hemovac drained 320 mL. Her chest tube drained 210 mL. At 2000, she drank 240 mL of water. Her IV was infusing @ 150mL/hour when report was received. She has voided 275 mL. 325 mL and 310 mL.

What is her I&O from 1400- 2200?

(Separate the answers with a comma)

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 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 caring for a client in labor. Which assessment finding will the nurse report to the charge nurse immediately?

The nurse is observing the fetal monitoring tracing pictured below. What type of deceleration will the nurse document?

The nurse is caring for a client in labor and discovers late decelerations of the fetal heart rate.
What does the nurse know as the reason for this type of deceleration?

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

Question

The physician ordered oxytocin 20 units in 1000 mL. LR to begin at 2 mU/min. What is the flow rate in mL/hr?

The nurse has received shift report for five clients admitted in labor. Which clients will the nurse anticipate delivering by a cesarean section? Select all that apply.

The nurse is caring for a client on the postpartum unit who had a vaginal delivery with epidural anesthesia 2 hours ago. 1. The client presses the call light and tells the nurse she needs to use the bathroom 2. The nurse arrives in the client's room 5 minutes later 3.

The client is getting out of bed alone What is the best response by the nurse?