A patient at 37 weeks gestation is admitted with ruptured membranes. What is the first priority action for the nurse?

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.

Correct Answer: B

Rationale: The correct answer is B: Instruct the patient to increase fluid intake and stand slowly. This recommendation is appropriate because the patient is likely experiencing orthostatic hypotension due to the expanding uterus compressing blood vessels, leading to decreased blood flow to the brain when standing. Increasing fluid intake helps maintain blood volume, while standing slowly helps prevent sudden drops in blood pressure. A: Rising quickly can worsen dizziness by further decreasing blood flow to the brain. C: Resting in bed may not address the underlying issue of orthostatic hypotension and may lead to deconditioning. D: Avoiding standing for long periods may be impractical and may not address the need to maintain adequate blood volume and prevent sudden drops in blood pressure.

Correct Answer: A

Rationale: The correct answer is A: offer emotional support. This is crucial as postpartum can be a challenging time emotionally. Providing emotional support helps the person cope with any feelings of anxiety, sadness, or overwhelm. Breastfeeding (B) and positioning assistance (C) are important but not the most critical aspect of discharge teaching. Non-pharmacological pain relief (D) is important but not as crucial as emotional support for overall well-being.

Correct Answer: A

Rationale: Fetal blood bypasses the liver through the ductus venosus by carrying blood directly to the inferior vena cava.

Correct Answer: C

Rationale: Acknowledging the client's feelings of being overwhelmed is the most supportive response. Offering solutions or reassurance without first addressing the client's emotions may not be as effective.

Correct Answer: D

Rationale: Celery is high in fiber and water, making it an effective choice for relieving constipation.

Correct Answer: B

Rationale: The correct answer is B: Monitoring blood glucose levels and maintaining a balanced diet. This is crucial for managing gestational diabetes, as it helps control blood sugar levels to prevent complications for both the mother and baby. Regular monitoring ensures timely adjustments to treatment. A balanced diet helps regulate blood sugar levels and provides essential nutrients for the baby's growth. Choice A is important but not as critical as monitoring blood glucose levels, as weight gain should be monitored but is not the primary focus in gestational diabetes. Choice C is not directly related to managing gestational diabetes. Choice D may be necessary in some cases, but it is not the most important aspect of care compared to monitoring blood glucose levels and diet.

Correct Answer: A

Rationale: The primary purpose of performing an episiotomy during delivery is to reduce the risk of perineal trauma. Episiotomy is a surgical incision made in the perineum to widen the vaginal opening during childbirth, which can help prevent severe tearing of the perineal tissue. This procedure is performed to provide controlled and precise incision, reducing the likelihood of extensive tears that may lead to complications such as infection or prolonged healing time. It is not done to promote faster delivery, facilitate fetal descent, or provide immediate fetal oxygenation. These choices do not accurately reflect the main goal of episiotomy, which is to minimize perineal trauma.

Correct Answer: A

Rationale: The correct answer is A: provide comfort measures. Comfort measures such as massage, positioning, and relaxation techniques help the laboring person cope with the pain and intensity of contractions. By providing comfort, the nurse can help reduce stress and anxiety, promoting a more positive labor experience. Choice B (assist with breathing exercises) can be helpful, but comfort measures are more essential for overall well-being during labor. Choice C (provide reassurance and comfort) is similar to the correct answer but lacks the specific action of providing comfort measures. Choice D (administer antibiotics) is irrelevant to the management of strong contractions and is not indicated unless there is a specific medical reason for antibiotics.