A pregnant patient at 28 weeks gestation reports lower 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 can help alleviate lower back pain during pregnancy. Poor posture and lack of exercise are common causes of back pain in pregnancy. Administering pain medication as in choice A may not address the root cause. Instructing the patient to lie flat on her back (choice C) can actually worsen back pain and pose risks during pregnancy. Performing a pelvic exam (choice D) is not necessary unless there are specific indications for it related to the patient's complaint. Therefore, choice B is the most appropriate initial action to address the lower back pain in this pregnant patient.

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.

Correct Answer: C

Rationale: The correct answer is C: lengthening of the umbilical cord. This is the most reliable indicator of placental separation because as the placenta detaches from the uterine wall, the cord lengthens as it moves downward. This signifies that the placenta has separated completely. A: A gush of clear amniotic fluid is not a reliable indicator of placental separation as it can occur before or after placental separation. B: Uterine contractions every 2 to 3 minutes are a sign of labor progression, not specifically placental separation. D: Maternal report of intense pain can be subjective and may not always indicate placental separation.