1. Which action should the nurse implement when preparing to measure the fundal height of a pregnant client?: Answer: To accurately measure the fundal height, the bladder must be empty to avoid elevation of the uterus. 2. The nurse identifies crepitus when examining the chest of a newborn who was delivered vaginally. Which further assessment should the nurse perform?-: Answer: The most common neonatal birth trauma due to a vaginal delivery is fracture of the clavicle. Although an infant may be asymptomatic, a fractured clavicle should be suspected if an infant has limited use of the affected arm, malposition of the arm, an asymmetric Moro reflex, crepitus over the clavicle, focal swelling or tenderness, or cries when the arm is moved. 3. One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action should the nurse take immediately?: Answer: Methergine is contraindicated for clients with elevated blood pressure, so the nurse should contact the healthcare provider and question the prescription