A pregnant patient at 24 weeks gestation reports feeling fatigued and lightheaded. What is the nurse's first priority action?

Correct Answer: B

Rationale: The correct answer is B. Monitoring the patient's blood pressure and assessing for signs of anemia is the first priority because fatigue and lightheadedness in pregnancy can be symptoms of anemia or other serious conditions. Anemia can lead to complications for both the mother and the baby. Encouraging rest and fluids (choice A) is important but should come after ruling out any potential serious conditions. Administering iron supplements (choice C) without proper assessment can be harmful if anemia is not the cause. Instructing the patient to avoid physical activity (choice D) without proper evaluation can delay necessary interventions.

Correct Answer: C

Rationale: The primary goal of fetal heart rate monitoring during the second stage of labor is to evaluate fetal well-being. This is crucial to ensure that the baby is tolerating labor and delivery well. Monitoring fetal heart rate helps identify any signs of distress or compromise in oxygen supply to the baby. It guides healthcare providers in making timely interventions if needed to prevent adverse outcomes. Choices A and B are incorrect because the primary goal is not about timing contractions or assessing uterine contractions strength. Choice D is incorrect as the focus is not on monitoring the vital signs of the birthing person but on assessing the well-being of the fetus.

Correct Answer: A

Rationale: The correct answer is A: every 15 minutes. During the first hour of the fourth stage of labor, immediate postpartum assessment is crucial to monitor for any signs of complications such as hemorrhage or shock. Assessing vital signs every 15 minutes allows for early detection of any abnormalities and prompt intervention. This frequency ensures close monitoring of the birthing person's condition and helps in early identification of any potential issues. Choices B, C, and D are incorrect because less frequent assessments may delay the identification of complications, potentially leading to serious consequences. Option C, in particular, is dangerous as it suggests delaying assessments when immediate postpartum monitoring is essential.

Correct Answer: A

Rationale: The correct answer is A: place the person in the knee-chest position. Placing the person in this position helps alleviate pressure on the umbilical cord, reducing the risk of compression and improving fetal oxygenation. Other choices like repositioning the laboring person or administering oxygen via mask do not directly address the issue of cord prolapse. Applying pressure to the cord can further compromise blood flow to the fetus. The knee-chest position is the most appropriate intervention as it helps relieve pressure on the cord and is crucial in managing umbilical cord prolapse effectively.

Correct Answer: A

Rationale: The correct answer is A: uterine overdistention. Uterine atony is when the uterus fails to contract effectively after childbirth. Overdistention, such as from multiple gestation or large baby, can stretch the uterus, leading to poor muscle tone. This results in inadequate contractions to control bleeding. Excessive uterine contractions (B) are not a common cause but rather can lead to other issues like uterine rupture. Placental abruption (C) is the premature separation of the placenta from the uterus, causing bleeding but not directly related to atony. Infection or retained placenta (D) can contribute to uterine atony but are not common primary causes.