20. A nurse is preparing to administer oxytocin to a client who is postpartum.

Which of the following findings is an indication for the administration of the

medication? (Select all that apply.)

Flaccid uterus is correct. Oxytocin increases the contractility of the uterus.

Excess vaginal bleeding is correct. Oxytocin enhances uterine contractility, decreasing

vaginal

bleedin

g.

21. A nurse is caring for a full-term newborn immediately following birth. Which of

the following actions should the nurse take first?

Dry the newborn

When using the urgent vs. nonurgent approach to client care, the nurse should determine that

the greatest risk to the newborn is cold stress. Therefore, the first action the nurse should take

immediately after delivery is to dry the newborn.

22. A nurse is performing a physical assessment of a newborn. Which of the

following clinical findings should the nurse expect? (Select all that apply.)

A heart rate of 154/min is correct. The expected reference range for a newborn's heart rate is

from 110/min to 160/min while awake.

A respiratory rate of 58/min is correct. The expected reference range for a newborn's

respiratory rate is from 30/min to 60/min.

A weight of 2.6 kg (5 lb 12 oz) is correct. The expected reference range for a newborn's

weight is from 2.5 to 4 kg (5.5 lb to 8.8 lb).

23. A nurse in an antepartal clinic is providing care for a client who is at 26 weeks of

gestation. Upon reviewing the client's medical record, which of the following findings should

the nurse report to the provider? (Click on the "Exhibit" button for additional information

about the client. There are three tabs that contain separate categories of data.)

Progress Notes

Fundal height 30 cm

Good fetal movement

Not experiencing headache, dizziness, blurred vision, or vaginal bleeding

Fetal heart rate 110/min

Fundal height measurement

A fundal height measurement of 30 cm should be reported to the provider. Fundal height

should be measured in centimeters and is the same as the number of gestational weeks plus or

minus 2 weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding