The nurse is caring for a pregnant patient at 32 weeks gestation who reports feeling lightheaded and faint when standing. What should the nurse recommend?

Correct Answer: A

Rationale: The correct answer is A: Increase fluid intake and avoid standing for long periods. This recommendation is appropriate for the patient's symptoms of lightheadedness and fainting, which could be due to dehydration or low blood pressure common in pregnancy. Increasing fluid intake can help maintain adequate blood volume and pressure. Avoiding prolonged standing can prevent pooling of blood in the lower extremities, reducing the risk of dizziness. Choices B, C, and D are incorrect: B: Taking deep breaths and rising quickly may worsen symptoms by causing a sudden drop in blood pressure. C: Complete rest and avoiding physical activity may not address the underlying issue of hydration or blood pressure. D: Sitting upright and avoiding bending forward may not directly address the need for increased fluid intake and reduced standing time.

Correct Answer: C

Rationale: The correct answer is C: Sleep with several pillows to elevate the upper body. Elevating the upper body with pillows can help relieve discomfort from heartburn, shortness of breath, and back pain commonly experienced during pregnancy. This position promotes better circulation and reduces pressure on the uterus. Incorrect choices: A: Taking a warm bath may help relax but does not address the underlying sleep issues. B: Sleeping on the back can compress major blood vessels, leading to decreased blood flow to the fetus. D: Taking sedatives is not recommended during pregnancy due to potential risks to the fetus.

Correct Answer: A

Rationale: The correct answer is A: Monitor vital signs. This is the most important intervention because changes in vital signs can indicate the presence of infection early on. By closely monitoring the postpartum person's vital signs, the nurse can promptly identify any signs of infection and initiate appropriate interventions. Educating on proper hygiene (B) and wound care (C) are essential but monitoring vital signs takes precedence in immediate infection detection. Encouraging ambulation (D) is beneficial for preventing complications like blood clots, but it is not the most crucial intervention for infection prevention in this scenario.

Correct Answer: A

Rationale: The correct answer is A (every 15 minutes) because immediate postpartum assessment is crucial for early detection of complications. Monitoring vital signs every 15 minutes allows for prompt identification of issues like hemorrhage or infection. Choice B (every 30 minutes) may lead to a delayed response to critical changes. Choice C (once, then hourly) may miss rapid changes in the first hour. Choice D (once, then every 4 hours) is too infrequent for the critical postpartum period. Regular monitoring is essential for ensuring maternal safety.

Correct Answer: D

Rationale: The correct answer is D because changing positions slowly helps prevent a sudden drop in blood pressure, which can cause lightheadedness. Sitting down immediately if feeling faint promotes safety and prevents falls. Taking deep breaths and lying flat on the back (choice A) can exacerbate lightheadedness by reducing blood flow to the brain. Increasing fluid intake and avoiding prolonged standing (choice B) may help with other issues but may not directly address the lightheadedness. Taking frequent rests while sitting upright (choice C) does not address the issue of changing positions slowly to prevent lightheadedness.