A pregnant patient at 32 weeks gestation reports a sudden headache and blurred vision. What is the nurse's priority action?

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: 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.

Correct Answer: A

Rationale: The correct answer is A: observe for respiratory effort. This is the first step because it helps the nurse quickly assess if the newborn is breathing effectively. Observing for respiratory effort allows for prompt identification of any potential respiratory distress or abnormalities. Taking the newborn's temperature (B) is important but not the first step in assessing respiratory status. Assisting with suctioning the airways (C) should only be done if there are signs of airway obstruction, not as the initial step. Suctioning the newborn's mouth (D) is not recommended immediately after birth unless there is clear obstruction, as this can stimulate unnecessary reflexes and cause harm.

Correct Answer: C

Rationale: The correct answer is C: to reduce the risk of seizures and cerebral hemorrhage. Magnesium sulfate is used during preterm labor to prevent and treat seizures in women with preeclampsia and eclampsia. It acts as a neuroprotective agent by preventing cerebral vasoconstriction and reducing the risk of cerebral hemorrhage. The other choices are incorrect because magnesium sulfate does not primarily relax the uterus to prevent contractions (A), improve fetal oxygenation (B), or decrease blood pressure (D) during preterm labor.