A pregnant patient at 32 weeks gestation reports swelling in the feet and hands. What should the nurse do first?

Correct Answer: A

Rationale: The correct answer is A: Monitor the patient's blood pressure and assess for signs of preeclampsia. At 32 weeks gestation, swelling in the feet and hands can be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. Monitoring blood pressure is crucial as elevated blood pressure is a key indicator of preeclampsia. Assessing for other signs of preeclampsia such as headache, visual disturbances, or upper abdominal pain is important for early detection and management. Prompt intervention is necessary to prevent complications for both the mother and the baby. Choices B, C, and D are incorrect because while elevation of feet, rest, hydration, and reducing sodium intake are important in managing mild swelling during pregnancy, in this case, the priority is to rule out preeclampsia which can lead to severe complications if left untreated. Assessing for blood clots or deep vein thrombosis is also important but

Correct Answer: C

Rationale: Rationale: Choice C is incorrect because headaches and dizziness are not considered normal symptoms of pregnancy, especially when accompanied by other signs of preeclampsia. Preeclampsia can cause headaches and dizziness due to high blood pressure. Choices A, B, and D are correct as they highlight important signs and symptoms of preeclampsia that the patient should report to their healthcare provider promptly.

Correct Answer: B

Rationale: The correct answer is B. Assess the patient for signs of anemia or other complications. At 36 weeks gestation, fatigue can be a sign of anemia, a common issue in pregnancy. Anemia can lead to complications for both the mother and the baby, so assessing for this is crucial. Encouraging rest (choice A) may help with fatigue temporarily but does not address the underlying cause. Administering iron supplements (choice C) without assessing first can be harmful if anemia is not the issue. Instructing the patient to increase caloric intake (choice D) is not the priority as it does not address the potential medical issue causing the fatigue.

Correct Answer: A

Rationale: The correct answer is A because position changes during the second stage of labor can indeed impact fetal descent. Different positions such as upright, squatting, or on hands and knees can help utilize gravity to aid in the descent of the baby through the birth canal. This can potentially speed up labor and reduce the risk of complications. Explanation of why the other choices are incorrect: B: Position changes are not intended to lead to support person stress, but rather to optimize the birthing process. C: Fetal descent is influenced by a combination of factors, including uterine contractions and maternal positioning. D: Maintaining a supine position is not always the safest option as it can compress blood vessels, potentially reducing blood flow to the baby.

Correct Answer: C

Rationale: The primary purpose of assessing the perineum during the fourth stage of labor is to detect any signs of perineal trauma. This assessment is crucial to identify any tears or lacerations that may require immediate medical attention. By checking for perineal trauma, the nurse can ensure proper healing and prevent complications postpartum. Summary: A: Evaluating readiness for discharge is not the primary purpose of perineal assessment during the fourth stage of labor. B: Ensuring safe ambulation is important but not the primary reason for assessing the perineum. D: Assessing cervical dilation is not relevant during the fourth stage of labor where the focus shifts to monitoring postpartum recovery.