A nurse is caring for a pregnant patient who is at 32 weeks gestation and reports frequent headaches and nausea. What should the nurse do first?

Correct Answer: A

Rationale: The correct answer is A: Monitor the patient's blood pressure and assess for signs of preeclampsia. At 32 weeks gestation, headaches and nausea could be symptoms of preeclampsia, a serious condition in pregnancy. Monitoring blood pressure is crucial as preeclampsia is characterized by high blood pressure. Assessing for signs of preeclampsia, such as proteinuria or visual disturbances, is essential for timely intervention. Administering anti-nausea medication or encouraging rest without addressing the possibility of preeclampsia could delay necessary treatment. Scheduling a follow-up appointment without immediate assessment could also put the patient at risk if preeclampsia is present.

Correct Answer: A

Rationale: The correct answer is A: The patient's blood pressure and hydration status should be assessed first because dizziness and lightheadedness can be indicative of hypotension or dehydration, common issues during pregnancy. Monitoring blood pressure will help determine if the symptoms are related to low blood pressure, and assessing hydration status can identify if the patient needs to increase fluid intake. Summary of other choices: B: Assessing fetal heart rate and activity is important but not the priority in this situation as the focus should be on the maternal health first. C: Checking hemoglobin and hematocrit levels is important for detecting anemia, but it is not the initial assessment for dizziness and lightheadedness. D: Monitoring weight gain and diet history are essential aspects of prenatal care but are not the immediate concerns when a pregnant patient is experiencing dizziness and lightheadedness.

Correct Answer: A

Rationale: The correct answer is A. Leg cramps and lower back pain in pregnancy can be relieved by taking a warm bath and performing leg stretches. Warm water helps relax muscles, while stretching can alleviate muscle tension. This is safe and effective for pregnant patients. Choice B is incorrect because applying a heating pad may not be recommended during pregnancy due to the risk of overheating. Resting in bed may provide temporary relief but does not address the underlying cause. Choice C is incorrect because increasing calcium intake and taking over-the-counter pain medications may not specifically target muscle cramps and back pain. It is essential to address the symptoms directly. Choice D is incorrect because encouraging light physical activity may be beneficial, but avoiding long periods of rest may not be necessary. Stretching and warm baths are more specific interventions for muscle cramps and back pain.

Correct Answer: B

Rationale: The correct answer is B: ultrasound. Ultrasound is the most accurate and non-invasive method to determine the presentation of the fetus by visualizing the position of the baby in the womb. It allows the nurse to see if the fetus is in a cephalic (head-down) or breech (feet or buttocks down) position. This information is crucial for assessing the progress of labor and planning appropriate interventions. A: Vaginal exam is not typically used to determine fetal presentation as it does not provide a clear view of the baby's position. C: Palpation of contractions helps assess the strength and frequency of contractions but does not directly determine fetal presentation. D: Laboring person interview may provide valuable information about symptoms and history but does not offer direct insight into fetal presentation.

Correct Answer: A

Rationale: The correct answer is A (30-60 seconds) for delayed cord clamping in an uncomplicated delivery. Delaying cord clamping for 30-60 seconds allows more blood to flow from the placenta to the baby, increasing the baby's hemoglobin levels and improving circulation. This extra blood transfer can provide the baby with essential nutrients and oxygen, reducing the risk of anemia and improving overall health outcomes. Choice B (15-30 seconds) may not provide enough time for sufficient blood transfer compared to the optimal window of 30-60 seconds. Choice C (30 seconds) is within the recommended range, but 30-60 seconds is considered more beneficial for maximizing blood flow to the newborn. Choice D (Delayed cord clamping is not recommended) is incorrect as delayed cord clamping has been shown to have various benefits for newborns when done in uncomplicated deliveries.