A pregnant patient at 32 weeks gestation reports persistent nausea and vomiting. What is the nurse's priority action?

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: 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.

Correct Answer: A

Rationale: The correct answer is A: administer a test dose of anesthesia. Before administering an epidural, it is crucial to perform a test dose to assess the person's response and ensure correct placement of the catheter. This step helps prevent potential complications such as unintentional intravascular injection. Summary: B: Ensuring informed consent is important but not the priority before administering the test dose. C: Administering IV fluids is important for hydration but not the immediate priority before the test dose. D: Continuous fetal monitoring is essential during labor, but it is not the priority before administering the test dose of anesthesia.