The nurse is caring for a pregnant patient at 24 weeks gestation who reports increased vaginal discharge. What should the nurse do first?

Correct Answer: A

Rationale: Rationale: Step 1: Assess characteristics of discharge - determining color and odor helps identify if it's normal or concerning. Step 2: Based on assessment, decide next steps - presence of abnormal color or odor may indicate infection or other issues. Step 3: Implement appropriate interventions - further evaluation or treatment as needed. Summary: - B: Resting and monitoring alone may not address the underlying cause of increased discharge. - C: While tracking amount is important, it doesn't provide immediate information on potential infection. - D: Performing a pelvic exam should come after initial assessment of discharge characteristics to guide further actions.

Correct Answer: B

Rationale: The correct answer is B: fetal descent. During the second stage of labor, assessing fetal descent is crucial to monitor progress. This data helps determine if the baby is moving down the birth canal appropriately. Fetal descent indicates the effectiveness of contractions and pushing efforts. It is a key indicator of labor progression. Rationale: - A: Fetal heart rate is important but primarily assesses fetal well-being, not progress during the second stage of labor. - C: Bearing-down effort is relevant for pushing but does not directly measure progress in terms of fetal descent. - D: Contraction strength is essential but does not specifically indicate the progress of the baby's descent in the birth canal during the second stage of labor.

Correct Answer: B

Rationale: The correct answer is B because a second-degree perineal laceration extends through the vaginal mucosa and perineal muscles. First, a second-degree laceration involves more than just the vaginal mucosa, as it also affects the perineal muscles. This type of laceration is more severe than a first-degree laceration, which only involves the vaginal mucosa. Second, due to the involvement of deeper structures like the perineal muscles, suturing is typically required to promote proper healing and prevent complications. Therefore, choice B is correct. Choices A and C are incorrect because a second-degree laceration involves more than just the vaginal mucosa and is not the least severe type of laceration. Choice D is incorrect because suturing is usually necessary for second-degree lacerations.

Correct Answer: B

Rationale: The correct answer is B, an increase in blood pressure, which is most likely to indicate the need for further evaluation during the first stage of labor. An increase in blood pressure could signal potential complications like preeclampsia or hypertension, which require immediate attention to ensure the safety of both the laboring person and the baby. A: A decrease in heart rate is not typically concerning during the first stage of labor, as it can be a normal response to relaxation or rest periods between contractions. C: An increase in pulse rate is expected during labor as the body works harder, so it may not necessarily indicate a need for further evaluation unless it is excessively high. D: No change in vital signs could be normal, but it is important to monitor for any signs of distress or complications even if vital signs remain stable.

Correct Answer: A

Rationale: The correct action for a nurse when a birthing person experiences late deceleration in fetal heart rate is to turn the laboring person to the left side. This helps improve placental perfusion by reducing pressure on the vena cava, enhancing blood flow to the uterus, and thus improving oxygenation to the fetus. This action can help alleviate the late deceleration and prevent fetal distress. Increasing maternal oxygen supply (choice B) is important but not the first-line intervention for late decelerations. Emergency cesarean section (choice C) is not typically indicated for late decelerations unless other interventions fail. Administering terbutaline (choice D) is not appropriate for late decelerations as it is a tocolytic used to inhibit uterine contractions and prevent preterm labor.