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Labor and delivery.

A client who had a vaginal delivery 2 hours earlier has just been transferred to the postpartum unit from labor and delivery. Which of the following nursing care goals is of highest priority?

1.       The client will breastfeed her baby every 2 hours.

2.       The client will consume a nutritious diet.

3.       The client will have a moderate lochial flow.

4.       The client will ambulate in the hallways every shift.

The nurse who has just performed a vaginal examination notes that the fetus is in the LOP position. Which of the following clinical assessments would the nurse expect to note at this time?

1.       Complaints of severe back pain.

2.       Rapid descent and effacement.

3.       Irregular and hypotonic contractions.

4.       Rectal pressure with bloody show.

A client with type 1 diabetes mellitus is 6 weeks pregnant. Her fasting glucose and hemoglobin A1C are noted to be 168 mg/dL and 12%, respectively. Which of the following nursing diagnoses is appropriate for the nurse to make at this time?

1.       Altered maternal skin integrity.

2.       Deficient maternal fluid volume.

3.       Risk for fetal injury.

4.       Fetal urinary retention.

A client who is 18 weeks’ gestation has been diagnosed with a hydatiform mole ( gestational trophoblastic disease). In addition to vaginal loss, which of the following signs/symptoms would the nurse expect to see?

1.       Hyperemesis and hypertension.

2.       Diarrhea and hyperthermia.

3.       Polycythemia.

4.       Polydipsia.


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