A nurse is caring for a pregnant patient who is at 40 weeks gestation and is experiencing a sudden increase in vaginal discharge. What is the nurse's priority action?

Correct Answer: A

Rationale: The correct answer is A because the sudden increase in vaginal discharge at 40 weeks gestation could indicate the onset of labor. Checking for signs of labor, such as contractions and assessing fetal heart rate, is crucial to determine if the patient is in active labor. This helps in timely intervention and ensuring the well-being of both the mother and baby. Summary: - Choice B: Encouraging rest and monitoring changes in discharge may not address the urgency of the situation. - Choice C: Performing a pelvic exam without assessing signs of labor or fetal well-being may delay necessary actions. - Choice D: While reporting to the healthcare provider is important, immediate assessment of labor signs and fetal heart rate takes precedence.

Correct Answer: A

Rationale: The correct answer is A: Perform a vaginal examination to assess for cord prolapse. This is the first priority action because cord prolapse is a life-threatening emergency that requires immediate intervention to prevent fetal compromise. By performing a vaginal examination, the healthcare provider can quickly determine if the umbilical cord is presenting before the fetus, allowing for prompt management. Choice B is incorrect because starting an IV and administering antibiotics is important but not the first priority in this situation. Choice C is incorrect as monitoring fetal heart rate for decelerations is essential but not as urgent as assessing for cord prolapse. Choice D is also incorrect as checking for meconium staining is important but does not take precedence over assessing for cord prolapse.

Correct Answer: A

Rationale: Correct Answer: A: Uterine rupture Rationale: 1. History of multiple cesarean sections increases the risk of uterine rupture. 2. Uterine rupture is a life-threatening complication for both mother and baby. 3. Signs include sudden severe abdominal pain, fetal distress, and hemodynamic instability. 4. Immediate intervention is crucial to prevent adverse outcomes. Summary: B: Precipitous labor - Quick labor is not specifically associated with multiple cesarean sections. C: Maternal hypotension - Important but not the most critical complication in this scenario. D: Fetal malpresentation - While important, it is not the most immediate concern compared to uterine rupture.

Correct Answer: C

Rationale: The correct answer is C: Sleep with several pillows to elevate the upper body. Elevating the upper body with pillows can help relieve discomfort from heartburn, shortness of breath, and back pain commonly experienced during pregnancy. This position promotes better circulation and reduces pressure on the uterus. Incorrect choices: A: Taking a warm bath may help relax but does not address the underlying sleep issues. B: Sleeping on the back can compress major blood vessels, leading to decreased blood flow to the fetus. D: Taking sedatives is not recommended during pregnancy due to potential risks to the fetus.

Correct Answer: B

Rationale: The correct answer is B: Check for cord prolapse. This is the first priority action because a prolapsed cord is a life-threatening emergency that requires immediate intervention to prevent fetal hypoxia and distress. The nurse should quickly assess for cord presentation by performing a vaginal exam and relieving pressure on the cord if present. Incorrect choices: A: Assess for signs of infection - While infection is a concern with ruptured membranes, it is not the immediate priority over checking for cord prolapse. C: Perform a vaginal exam to assess cervical dilation - Assessing cervical dilation can wait until after ruling out cord prolapse. D: Perform a vaginal examination to check for fetal descent - Fetal descent assessment is not urgent compared to checking for cord prolapse in this scenario.