A client delivers a viable infant, but begins to have excessive uncontrolled vaginal Notifying the health care provider of the clients’ condition, what information is most Maternal blood pressure An infant born to a heroin-addicted mother is admitted to the neonatal care, unit. What behaviors can the to exhibit? Irritability and a high-pitched cry A multigravida, full-term laboring client complains of “back labor”. Vaginal examination reveals that the client’s 3 cm with 50% effacement and the fetal head is at -1 station. What should the nurse implement? Apply counter-pressure to the sacral area A client with gestational diabetes is undergoing a non-stress test (NST) at 34-week gestational is 144 beats/minute. The client is instructed to mark the fetal monitor by pressing a b each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. What Two FHR accelerations of 15 beats/minute x 15 seconds are recorded A postpartal client complaisn that she has the urge to urinate every hour but is only able to void a small amount. What interventions provides the nurse with the most useful information? Catheterize for residual urine after next voiding During a 26-week gestation prenatal exam, a client reports occasional dizziness What intervention is best for the nurse to recommend to this client? Lie on the left or right side when sleeping or resting Artificial rupture of the membrane of a laboring reveals meconium-stained fluid, what is the priority? Have a meconium aspirator available at delivery A 6-year-old child with acute infectious diarrhea is placed on a rehydration therapy Which action should the nurse instruct the parents to take if the child begins to vomit? Continue giving ORS frequently in small amounts A client is receiving oxytocin (Pitocin ) to augment early labor. Which assessment is most important time the infusion rate is increases? Contraction pattern An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds tachypneic, and hypotonic. What is the first action that the nurse should take? Determine the infant’s blood sugar level A toddler with a history of an acyanotic heart defect is admitted to the pediatric intensive 2 Rate of 60 breaths/ minute, and a heart rate of 150 beats/minute. What action should the nurse take? Obtain a pulse oximeter reading While undergoing hemodialysis, a male client suddenly complains of dizziness. He is alert and oriented, but his skin is cool and clammy. His vital signs are: heart rate 128 beats/minute, respirations 18 breaths/minute, and blood pressure 90/60. Which intervention should the nurse implement first? Raise the client’s legs and feet When caring for a client who has acute respiratory distress syndrome (SRDS), the nurse elevates the head of the bed 30 degrees. What is the reason for this intervention? To reduce abdominal pressure on the diaphragm Which breakfast selection indicates that the client understands the nurse’s instructions about the dietary management of osteoporosis? Bagel with jelly and skim milk A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him “feel bad”. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition? Stroke secondary to hemorrhage A 60-year-old female client with a positive family history of ovarian cancer has developed an abdominal mass and is being evaluated for possible ovarian cancer. Her Papanicolau (Pap) smear results are negative. What information should the nurse include in the client’s teaching plan? Further evaluation involving surgery may be needed A client who recently underwear a tracheostomy is being prepared for discharge to home. Which instructions is most important for the nurse to include in the discharge plan? Teach tracheal suctioning techniques During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate firs? Respiratory apnea of 30 seconds A client who is taking an oral dose of a tetracycline complains of gastrointestinal upset. What snack should the nurse instruct the client to take with the tetracycline? Toasted wheat bread and jelly At 0600 while admitting a woman for a schedule repeat cesarean section (C-Section), the client tells the nurse that she drank a cup a coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first? Inform the anesthesia care provider