1. A woman delivered her infant 24 hours ago by cesarean section. Which assessment findings require immediate nursing action? Select all that apply.

A. Fundal height is one fingerbreadth below the umbilicus
B. Lochia rubra 2x5 cm in size
C. Uterus feels boggy
D. The patient reports breakthrough pain level of 7.4
E. The patient’s abdomen is mildly distended, and bowel sounds are hypoactive

2. A nurse is assigned to care for a pregnant client who presents to the emergency department alone with a report of decreased fetal movement. Exams reveal bruising on the abdomen. When questioned about how that happened, the client reported her toddler jumped on her. The client appears distressed. When providing care to this client, which intervention will have priority?

A. Building trust
B. Promoting privacy
C. Notifying child protective services
D. Completing documentation

3. A newborn has a respiratory rate of 80 breaths/min, nasal flaring with sternal retraction, a heart rate of 150 beats/min, a temperature of 36°C (98.8°F), and oxygen saturation of <87%. The nurse interprets these findings as:

A. Cardiac distress
B. Respiratory alkalosis
C. Pneumonia
D. Respiratory distress

4. The nurse is managing a woman receiving an oxytocin infusion for labor induction. 30 minutes have passed. The Pitocin is at 4 milliunits/min, and contractions are every 6-7 minutes lasting 60 seconds. Uterine resting tone remains at 20 mmHg. Which action would be most appropriate?

A. Slow the oxytocin infusion to the initial rate
B. Continue to monitor contractions and fetal heart rate
C. Stop the infusion immediately
D. Increase the oxytocin infusion by 2 milliunits/minute

1.The assessment findings that require immediate nursing action are Uterus feels boggy and The patient reports break through pain level of 7.4(C and D).

2.The intervention that will have priority in this situation is Notifying child protective services(C)

3.The nurse interprets these findings as respiratory distress(D)

4.The most appropriate action in this situation would be continue to monitor contractions and fetal heart rate(B).

1.The assessment findings that require immediate nursing action are:

C. Uterus feels boggy - This indicates uterine atony, which could lead to excessive bleeding and should be addressed promptly.

D. The patient reports breakthrough pain level of 7.4 - Breakthrough pain could indicate inadequate pain management and needs to be addressed to ensure the patient's comfort.

2.The intervention that will have priority in this situation is:

C. Notifying child protective services - The presence of bruising on the pregnant client's abdomen and the reported cause raise concerns about potential abuse. Ensuring the safety of both the client and her unborn child is a top priority.

3.The nurse interprets these findings as:

d. respiratory distress - The newborn's signs and symptoms, including nasal flaring, sternal retractions, increased heart rate, low oxygen saturation, and rapid respiratory rate, indicate respiratory distress. This could be due to a variety of underlying causes and needs prompt attention.

4.The most appropriate action in this situation would be:

b. continue to monitor contractions and fetal heart rate - The current assessment findings (contractions every 6-7 minutes lasting 60 seconds, uterine resting tone at 20mmHg) suggest that labor induction is progressing appropriately. Monitoring the contractions and fetal heart rate allows for ongoing assessment of the patient's condition before making any changes to the oxytocin infusion rate.

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