A nurse is caring for a client who is one day postpartum and has a perineal laceration. The nurse assesses the laceration for all of the following except: 

A pregnant woman at 20 weeks’ gestation exhibits the following signs of pregnancy during a routine prenatal checkup. Which one is categorized as a probable sign of pregnancy?

A newborn that is 2 hours old is being assessed. The nurse notes the respiratory rate to be between 40 and 46 breaths per minute. The rhythm is irregular and the infant has two brief episodes of apnea that last less than 10 seconds. The nurse should do which of the following?   

A woman provides the nurse with the following obstetrical history: Delivered a daughter, now 5 years old, at 39 weeks’ gestation; had a miscarriage 3 years ago, and had a first-trimester abortion 2 years ago. She is currently pregnant. Which of the following portrays an accurate picture of this woman’s GTPAL?

A newborn that is 2 hours old is being assessed. The nurse notes the respiratory rate to be between 40 and 46 breaths per minute. The rhythm is irregular and the infant has two brief episodes of apnea that last less than 10 seconds. The nurse should do which of the following?   

A newborn infant reacts to a sudden loud noise by simultaneously fanning the fingers, with the thumbs and forefingers forming the letter C, while the arms and legs are thrown outward and then brought together. The nurse should evaluate this response as:

The postpartum client has chosen to breastfeed her infant. Which of the following would the nurse teach the mother to do to help with breastmilk production?

A nurse is assessing a postpartum client for fundal height, location, and consistency. The fundus is noted to be displaced laterally and there is uterine atony. The nurse should identify which of the following conditions as the cause of the uterine atony?

A client verbalizes to a mental health counselor that his life is meaningless since his wife divorced him and that he no longer wants to live.  What nursing diagnosis, resulting from his spiritual distress, would be appropriate?

A nurse asks the mother of a hospitalized client age 2 years to bring in his favorite blanket or stuffed animal.  What sense is the nurse trying to stimulate with this intervention?