A pregnant patient at 34 weeks gestation is concerned about the possibility of preterm labor. Which of the following is the most appropriate action for the nurse to take?

Correct Answer: A

Rationale: The correct answer is A. Monitoring the fetal heart rate and checking for signs of labor is the most appropriate action as it allows the nurse to assess the status of the pregnancy and the potential onset of preterm labor. This proactive approach helps in early identification and management of any concerning signs or symptoms. Administering magnesium sulfate (choice B) is not appropriate without proper assessment and indication. Encouraging rest and symptom monitoring (choice C) is beneficial but may not be sufficient for evaluating preterm labor. Recommending the patient lie flat on her back for 24 hours (choice D) is not evidence-based and could potentially cause harm.

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.

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.