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?

A 3-year-old female patient woke up this morning feeling agitated and with a fever of 103.4° F (39.7° C). She was crying yesterday and reported back pain.

She has a history of asthma controlled by daily cetirizine and occasional albuterol.

She has had two urinary tract infections (UTIs) in the past 4 months.

Given the patient’s history and current condition, which condition is she most likely experiencing, what actions should the nurse take, and what parameters should the nurse monitor?

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.

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?

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?

After a 14-day antibiotic treatment for bacterial meningitis in an infant, the nurse is preparing the family for discharge.  Monitor the infant for response to auditory stimuli. 

The nurse is evaluating the growth and development of a 3-year-old child.
Which speech and language skills should the nurse identify as normal developmental milestones for this child?

The nurse is instructing the parent of a 10-year-old child newly diagnosed with type 1 diabetes mellitus (DM) on how to administer subcutaneous insulin injections.

The parent expresses a fear of needles and is unable to perform the procedure.

What intervention 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?

A 3-year-old male was brought into the emergency room this morning with a sudden onset of “fast and noisy breathing”. What other symptoms is the nurse likely to note in a child diagnosed with epiglottitis?