A pregnant patient is at 24 weeks gestation and reports occasional cramping and lower abdominal discomfort. What should the nurse do first?

Correct Answer: A

Rationale: The correct answer is A: Assess for signs of preterm labor and monitor the patient for regular contractions. This is the most appropriate action as the patient is experiencing cramping and lower abdominal discomfort, which could indicate preterm labor. Step 1: Assessing for signs of preterm labor, such as regular contractions, is crucial to determine the patient's condition. Step 2: Monitoring the patient for regular contractions helps in identifying any patterns and assessing the progression of labor. Other choices are incorrect as B: Administering pain medications without assessing for preterm labor can mask important indicators. C: Performing a pelvic exam may increase the risk of infection and is not the priority. D: Instructing the patient to increase fluid intake may not address the potential risk of preterm labor.

Correct Answer: A

Rationale: The correct answer is A: Monitor the patient's blood pressure and check for signs of preeclampsia. 1. Headaches and blurred vision are common symptoms of preeclampsia. 2. Preeclampsia is a serious condition that can lead to complications for both the mother and baby. 3. Monitoring blood pressure is crucial in diagnosing preeclampsia and determining the appropriate course of action. 4. Prompt assessment and management of preeclampsia are essential to prevent further complications. Incorrect choices: B: Administering pain relief and encouraging rest does not address the underlying cause of the symptoms, which could be preeclampsia. C: Assessing vision and scheduling an appointment with an eye specialist does not address the urgent need to assess for preeclampsia. D: Encouraging fluid intake and avoiding strenuous activity may be helpful in general, but they do not address the potential seriousness of preeclampsia in this

Correct Answer: C

Rationale: The correct answer is C: every 5-15 minutes. During the second stage of labor, frequent assessment of the fetal heart rate is crucial to monitor fetal well-being and detect any signs of distress promptly. Assessing every 5-15 minutes allows the nurse to closely monitor the fetal heart rate pattern and response to uterine contractions, ensuring timely interventions if needed. Option A (every 5 minutes with contractions) may be too frequent and unnecessary, causing patient discomfort. Option B (at least every 30 minutes) is too infrequent and may miss important changes in fetal status. Option D (only when the physician orders assessment) is incorrect as nurses should proactively monitor fetal well-being without waiting for physician orders.

Correct Answer: A

Rationale: The correct answer is A: oxytocin (Pitocin). Oxytocin is commonly used postpartum to prevent hemorrhage and promote uterine contractions due to its ability to stimulate uterine muscle contractions. Oxytocin plays a crucial role in the physiological process of labor and delivery by helping the uterus contract and reduce bleeding. Fentanyl (B), epinephrine (C), and lorazepam (D) are not uterotonic medications and do not have the same effects on the uterus as oxytocin. Fentanyl is an opioid analgesic, epinephrine is a vasoconstrictor, and lorazepam is a sedative, none of which are indicated for preventing postpartum hemorrhage or promoting uterine contractions.

Correct Answer: A

Rationale: The purpose of Leopold's maneuver in labor and delivery is to assess fetal presentation and position. Step 1 evaluates the fundal grip to determine the fetal part. Step 2 assesses the sides of the abdomen to identify the fetal back. Step 3 determines the presenting part and position. Step 4 confirms the presenting part and its mobility. This systematic approach helps determine the position of the fetus in the uterus. Choices B, C, and D are incorrect as they do not align with the specific purpose of Leopold's maneuver, which is primarily focused on assessing fetal presentation and position.