A nurse makes the following observations when assessing a full-term baby who nursed for fifteen minutes and is being assessed at forty-five minutes post-birth: 9 lb 2 oz (4,139 grams), 21 inches long, TPR: Temp is 96.6 F (35.9 C), heart rate is 158, respiratory rate is 56, extremities are jittery, acrocyanosis is present, and he is sleepy.  Which of the following nursing actions is of the highest importance? 

The nurse is caring for a client in the first hour postoperatively who had a cesarean section. During the first hour, the nurse will check the vital signs, pain, incision, uterine fundus, and lochia 

The nurse assesses a neonate born at 39 weeks gestation via Cesarean section. The neonate has nasal flaring, grunting, and intercostal retractions. The respiratory rate is 82 breaths per minute, and there are crackles in the lungs on auscultation. The nurse suspects the newborn is having difficulty clearing the fluid from the lungs. What is the nurse’s assessment of the neonate’s most likely condition?

A client is diagnosed with a threatend abortion. Which explanation by the nurse is the best description of this diagnosis?

The nurse is caring for a client in labor who is at 10 cm dilation. She performs a sterile vaginal exam and feels the anterior fontanel at 10 o’clock and the posterior fontanel at 4 o’clock. The nurse suspects the fetus is in what position?  

Assessment of a client in labor reveals cervical dilation of 3 cm, cervical effacement of 30%, and contractions occurring every 7 to 8 minutes, lasting about 40 seconds. The nurse determines that this client is in:

The client presents for a preconception visit. Which statement by the client indicates there may be a risk for a future pregnancy?

The nurse cares for a client who is G1P0 at 40 weeks gestational age who is experiencing labor. She is going natural and was 6 cm dilated two hours ago. She has been laboring in the shower with the nurse intermittently listening to the fetal heart rate using a handheld Doppler. She calls out and thinks she may have had a spontaneous rupture of membranes. The nurse enters the room. His priority assessment is

The nurse is observing the fetal heart rate tracing of a client who had an artificial rupture of membranes (AROM) fifteen minutes ago. After seeing periodic variable decelerations with each contraction, the nurse performs a sterile vaginal exam and feels the pulsations of the umbilical cord ahead of the fetal presenting part. The nurse prioritizes

Fiber-optic cable uses a protected string of _____ that transmits beams of light.