A nurse is caring for a pregnant patient who is at 24 weeks gestation and reports feeling fatigued and weak. What is the most appropriate action for the nurse to take?

Correct Answer: A

Rationale: The correct answer is A: Assess the patient's hemoglobin levels to check for anemia. Fatigue and weakness are common symptoms of anemia, especially in pregnant women. By assessing the hemoglobin levels, the nurse can determine if the patient is anemic and needs appropriate treatment. This step is crucial for identifying and addressing the underlying cause of the symptoms. Summary: B: Recommending a high-calorie diet may not address the root cause of the fatigue and weakness, which could be anemia. C: While rest is important during pregnancy, simply encouraging rest without investigating the cause of the symptoms may delay appropriate treatment. D: While gentle exercises can be beneficial during pregnancy, they may not be suitable if the patient is experiencing significant fatigue and weakness due to anemia.

Correct Answer: A

Rationale: The correct answer is A. Monitoring the fetal heart rate and checking for signs of labor is the most appropriate action as it allows the nurse to assess the status of the pregnancy and the potential onset of preterm labor. This proactive approach helps in early identification and management of any concerning signs or symptoms. Administering magnesium sulfate (choice B) is not appropriate without proper assessment and indication. Encouraging rest and symptom monitoring (choice C) is beneficial but may not be sufficient for evaluating preterm labor. Recommending the patient lie flat on her back for 24 hours (choice D) is not evidence-based and could potentially cause harm.

Correct Answer: A

Rationale: The correct answer is A: Assess the patient's blood pressure and check for signs of preeclampsia. This is the priority action because sudden headache and blurred vision are symptoms of preeclampsia, a serious condition in pregnancy. Step 1: Assessing blood pressure is crucial to identify hypertension, a hallmark of preeclampsia. Step 2: Checking for other signs of preeclampsia, such as proteinuria and edema, helps confirm the diagnosis. Step 3: Prompt intervention is necessary to prevent complications for both the mother and the baby. Choices B, C, and D are incorrect because they do not address the potential life-threatening condition of preeclampsia and may delay appropriate treatment.

Correct Answer: B

Rationale: The correct answer is B: Monitor the patient's hydration status and assess for signs of dehydration. This is the priority action because nausea and vomiting during pregnancy can lead to dehydration, which can have serious consequences for both the mother and the baby. By monitoring the patient's hydration status and assessing for signs of dehydration, the nurse can ensure early intervention if dehydration occurs. Incorrect choices: A: Instruct the patient to take over-the-counter anti-nausea medication - This is not the priority as dehydration needs to be addressed first. C: Encourage the patient to eat large meals more frequently to prevent nausea - This may exacerbate the nausea and vomiting, leading to further dehydration. D: Recommend the patient avoid drinking fluids to prevent further vomiting - Dehydration can worsen if the patient avoids fluids.

Correct Answer: C

Rationale: The correct answer is C because documenting the fetal heart rate (FHR) and characteristics of amniotic fluid is crucial to assess fetal well-being and monitor for signs of distress. This information helps guide further management decisions. Administering an epidural (A) is not the priority at this stage. Starting an IV line and administering antibiotics (B) may be needed later but not the immediate priority. Preparing for immediate delivery (D) is premature without assessing the fetal status first.