1. A nurse is assessing a client who is at 33 weeks of gestation. Which of the following findings

should the nurse report to the provider?

a. Epigastric pain: The nurse should notify the provider of the client's report of epigastric pain

because this is a manifestation of preeclampsia. Other findings the nurse should report include

severe headache, blurred vision, confusion, nausea and vomiting, and decreased urinary output.

b. Leukorrhea: Leukorrhea, or vaginal discharge, is an expected finding throughout pregnancy. Leukorrhea increases

during pregnancy due to hypertrophy of the cervix, which increases the amount of mucus secreted from the vagina.

c. Excessive salivation: Ptyalism, or excessive salivation, is an expected finding in pregnancy. Increased levels of estrogen

cause an increase in the production of saliva.

d. Darkening of the skin on the face: Hyperpigmentation on the face, or melasma, is an expected finding during

pregnancy. The anterior pituitary gland increases the production of melanocyte-stimulating hormone, causing an

increase in pigmentation of the skin.

2. A nurse is assessing a newborn following a circumcision 48 hr ago. The nurse should identify

that yellow exudate covering the newborn's glans penis indicates which of the following?

a. Wound infection: Infected circumcision wounds appear swollen with a purulent discharge.

b. Ulceration: Yellow exudate following a circumcision is not a manifestation of an ulceration.

c. Exposure to urine: Yellow exudate is not a manifestation resulting from the wound being exposed to urine.

d. Healing: After 24 hours, yellow exudate usually forms over the glans penis and remains for the

next 2 to 3 days. It sometimes forms a crust, which is expected. The nurse should explain that

the yellow film the guardians will see is granulation tissue as the circumcision heals. The

guardians should not remove this tissue.

3. A nurse is developing a plan of care for a client who is in the latent phase of labor. Which of

the following interventions should the nurse include in the plan to manage the client's pain?

a. Encourage the client to listen to music: During the latent phase of labor, the nurse should

implement nonpharmacological strategies to encourage relaxation and provide pain relief. There

are a wide variety of cutaneous and sensory measures that are simple to implement during this

stage of labor, such as music, rocking, breathing techniques, walking and application of hot or

cold packs.

b. Instruct the client how to use biofeedback: Biofeedback can be an effective method to reduce the discomfort of labor

by promoting self-awareness and relaxation. However, the client must have received instruction and practiced this

technique prior to labor for it to be effective.

c. Administer fentanyl 100 mcg every hour via intermittent IV bolus…Fentanyl is an opioid agonist analgesic that

enhances a client's ability to rest between contractions. However, opioids can also inhibit uterine contractions and

prolong labor. Therefore, avoid administration of opioid analgesia until a client reaches the active phase of labor or

cervical dilation of at least 4 cm.