Correct Answer: C

Rationale: Crackles in bilateral lung bases indicate fluid accumulation or infection in the lungs, a concerning finding in pneumonia that may suggest worsening condition or complications like pulmonary edema, requiring immediate reporting.
Choice A is incorrect because an oxygen saturation of 92% is borderline but not immediately alarming in pneumonia, especially if the client is receiving oxygen; it should be monitored.
Choice B is incorrect because a respiratory rate of 24/min is slightly elevated but expected in pneumonia and not the priority to report.
Choice D is incorrect because a temperature of 37.8°C is a low-grade fever, common in pneumonia, and does not require immediate reporting unless persistent or accompanied by other symptoms.

Correct Answer: B

Rationale: Swelling in the affected leg may indicate deep-vein thrombosis, requiring provider notification. Pain, mild fever, and normal heart rate are expected.

Correct Answer: C

Rationale: Placing sterile gauze over areas of spilled solution within the sterile field is incorrect. If solution is spilled within the sterile field, the entire field should be considered contaminated and a new sterile field should be set up. Holding the irrigation solution bottle with the label facing away from the palm of the hand is incorrect. The label should face the palm of the hand to avoid contamination of the sterile field. Removing the cap and placing it sterile-side up on a clean surface is correct. This ensures that the sterile side of the cap remains sterile and can be used to recap the bottle after pouring the solution. Holding the bottle in the center of the sterile field when pouring the solution is incorrect. The bottle should be held over the edge of the sterile field to avoid contamination of the field if solution spills.

Correct Answer: A

Rationale: Decreased fetal movement is a concerning finding that may indicate fetal distress or compromise, requiring immediate reporting to the provider for further evaluation, such as a nonstress testisbn or biophysical profile.
Choice B is wrong because a blood pressure of 120/80 mm Hg is within the normal range for pregnancy and does not require reporting.
Choice C is wrong because a fundal height of 36 cm at 36 weeks is normal, as fundal height in centimeters typically corresponds to gestational age (±2 cm).
Choice D is wrong because mild ankle edema is a common, benign finding in late pregnancy due to increased fluid retention and pressure from the gravid uterus, and it does not typically require reporting unless accompanied by other symptoms like sudden swelling or signs of preeclampsia.

Correct Answer: A

Rationale: Encouraging the client to push with each contraction during the second stage of labor (from full cervical dilation to delivery) is appropriate, as it facilitates fetal descent and delivery, aligning with the client's natural urges to push.
Choice B is wrong because positioning the client supine with legs elevated is not recommended; it can compress the inferior vena cava, reduce uterine blood flow, and impede pushing efforts. Upright or lateral positions are preferred.
Choice C is wrong because applying fundal pressure is not a standard practice and can cause maternal or fetal injury, such as uterine rupture or shoulder dystocia.
Choice D is wrong because instructing the client to hold her breath while pushing (Valsalva maneuver) can decrease oxygen to the fetus and increase maternal fatigue; open-glottis pushing (exhaling while pushing) is preferred.