A pregnant patient at 36 weeks gestation reports feeling more tired than usual. What is the nurse's priority action?

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: 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.

Correct Answer: D

Rationale: The correct answer is D: to prevent infection and promote early bonding. Rh immunoglobulin (RhIg) is given to prevent Rh sensitization in Rh-negative individuals who have given birth to an Rh-positive baby. This prevents the mother from developing antibodies that could harm future pregnancies. The other choices are incorrect because RhIg does not promote lactation (B), reduce the risk of bleeding in Rh-negative pregnancies (C), or prevent Rh sensitization in future pregnancies (A). By preventing infection, RhIg helps protect the mother's health and promotes early bonding with the newborn.

Correct Answer: A

Rationale: The correct answer is A: place the person in the knee-chest position. This is the priority nursing action because it helps relieve pressure on the cord and prevents further prolapse. Placing the person in the knee-chest position also promotes optimal fetal oxygenation. Administering oxygen via mask (choice B) is important but not the priority. Applying pressure to the cord (choice C) should never be done as it can further compromise blood flow to the fetus. Administering an epidural (choice D) is not the priority in this emergency situation.

Correct Answer: B

Rationale: The correct answer is B: encourage deep breathing exercises. Deep breathing helps prevent complications like pneumonia after surgery, aids in lung expansion, and promotes overall respiratory health. Choice A is important but not the most crucial post-cesarean. Choice C promotes mobility but doesn't address immediate respiratory needs. Choice D is important but not the most vital in the early postpartum period.