A patient with gestational hypertension is being monitored during labor. What is the most important factor to assess?

Correct Answer: B

Rationale: The correct answer is B: Blood pressure. In a patient with gestational hypertension, monitoring blood pressure is crucial to assess for worsening hypertension, which can lead to complications such as preeclampsia and eclampsia. Elevated blood pressure can affect both maternal and fetal well-being. Assessing fetal heart rate (A) is important but not the most critical factor in this scenario. Uterine contractions (C) are important but secondary to monitoring blood pressure. Fetal malpresentation (D) can impact delivery but is not the most vital factor to assess in a patient with gestational hypertension.

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 correct answer is A (every 15 minutes) because immediate postpartum assessment is crucial for early detection of complications. Monitoring vital signs every 15 minutes allows for prompt identification of issues like hemorrhage or infection. Choice B (every 30 minutes) may lead to a delayed response to critical changes. Choice C (once, then hourly) may miss rapid changes in the first hour. Choice D (once, then every 4 hours) is too infrequent for the critical postpartum period. Regular monitoring is essential for ensuring maternal safety.

Correct Answer: A

Rationale: The correct answer is A: Signs and symptoms of preterm labor. At 22 weeks gestation, it is crucial to educate the patient about potential signs of preterm labor to help prevent premature birth and ensure the well-being of the baby. Symptoms such as regular contractions, abdominal cramping, backache, and vaginal bleeding should be discussed. This topic is time-sensitive and requires immediate action if observed. Summary of other choices: B: Signs of gestational diabetes - While important, monitoring for gestational diabetes typically occurs later in pregnancy, usually around 24-28 weeks. C: Breastfeeding education - Important, but not as time-sensitive as preterm labor education. D: Postpartum care - Relevant but more appropriate for later stages of pregnancy or after birth, not specifically at 22 weeks gestation.

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.