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Which of the following actions should the nurse perform at this time?

A client’s vital signs during labor and delivery were: BP 100/58–110/66,

T 98.6ºF–98.8ºF, P 72–80 bpm, R 20–24 rpm. The client’s vitals 2 hours postpartum are BP 100/56, TPR 99.4ºF, P 70 bpm, R 20 rpm. Which of the following actions should the nurse perform at this time?

1.       Check the client’s lochia flow.

2.       Ask the client if she is having chills.

3.       Encourage the client to drink fluids.

4.       Assess the client’s lung fields.

A G1 P0000 gravida, whose labor was uneventful, delivered 1 minute ago. The baby’s Apgar score at this time is 3. Which of the following actions is appropriate for the nurse to make?

1.       Administer ophthalmic prophylaxis.

2.       Place the baby on the abdomen of the mother.

3.       Obtain assistance for neonatal resuscitation.

4.       Repeat the score to confirm its accuracy.

The nurse has identified the following nursing diagnosis for a postpartum (PP) client: Potential for fluid volume deficit. Which of the following goals for the mother is appropriate?

1.       Minimal perineal pain.

2.       Normal lochial flow.

3.       Normal temperature.

4.       Weight reduction.

2.An infant of a diabetic mother, 40 weeks’ gestation, weight 4,500 grams, has just been admitted to the neonatal nursery. The neonatal intensive care nurse will monitor this baby for which of the following? Select all that apply.

                                 i.            Hyperreflexia.

                               ii.            Hypoglycemia.

                              iii.            Respiratory distress.

                              iv.            Opisthotonus.

                               v.            Nuchal rigidity.


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