A pregnant patient at 28 weeks gestation is experiencing mild back pain. What should the nurse do first?

Correct Answer: B

Rationale: The correct answer is B because assessing the patient's posture and recommending appropriate exercises will help address the mild back pain effectively without compromising the safety of the pregnancy. By identifying any postural issues contributing to the pain and recommending suitable exercises, the nurse can promote musculoskeletal health and alleviate discomfort. Administering pain relief without addressing the underlying cause (choice A) may mask symptoms temporarily. Encouraging light physical activities (choice C) could worsen the pain if not tailored to the individual's needs. Instructing the patient to rest and take deep breaths (choice D) may not address the root cause of the back pain.

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 correct answer is C because encouraging the patient to rest in an upright position helps improve lung expansion and oxygenation, relieving the difficulty in breathing. By monitoring symptoms, the nurse can assess for any worsening signs or the need for further intervention. A: Administering oxygen and preparing for delivery is premature without assessing the patient further. B: Lying on the left side may alleviate pressure on the diaphragm but does not address the underlying cause of difficulty breathing. D: Instructing to take deep breaths and elevate legs may not be beneficial and could potentially worsen the symptoms.

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.