The nurse is caring for a pregnant patient who is 38 weeks gestation and has a history of gestational hypertension. Which of the following symptoms would indicate the need for immediate medical attention?

Correct Answer: B

Rationale: The correct answer is B: Headaches and blurred vision. These symptoms can indicate a serious condition called preeclampsia, which can be life-threatening for both the mother and the baby. Headaches and blurred vision are signs of increased blood pressure and potential organ damage. Immediate medical attention is crucial to monitor and manage preeclampsia. A: Mild swelling in the feet and ankles is common in pregnancy and not necessarily indicative of a serious issue. C: Occasional lower back pain is also common in pregnancy and may not require immediate medical attention. D: Fatigue and slight nausea are common pregnancy symptoms and do not typically indicate a need for immediate medical attention.

Correct Answer: C

Rationale: The correct answer is C because it suggests a misconception that the patient only needs to see the doctor once during pregnancy. This is incorrect as prenatal care involves multiple visits to monitor both the mother's and baby's health. A: Correct - Prenatal visits monitor baby's growth. B: Correct - Early detection of complications is crucial. D: Correct - Regular visits ensure the mother's health. C: Incorrect - Seeing the doctor only once is inadequate prenatal care and can lead to missed opportunities for early intervention.

Correct Answer: D

Rationale: The correct answer is D because the nurse's priority action in this scenario is to report the rupture of membranes to the healthcare provider immediately. This is crucial to ensure timely assessment and management to prevent infection and monitor for potential complications. Checking fetal heart rate and vital signs (A) can be important but not as urgent as reporting the rupture of membranes. Encouraging the patient to go home and rest (B) is inappropriate as leaking clear fluid at 40 weeks gestation may indicate rupture of membranes. Instructing the patient to monitor fetal movement and call back (C) is not sufficient as immediate medical attention is needed in case of ruptured membranes.

Correct Answer: D

Rationale: The correct answer is D because attending all prenatal visits and following the doctor's advice is crucial for monitoring the health of both the mother and the baby. It ensures early detection of any potential issues and proper management throughout the pregnancy. This statement shows the patient's commitment to their prenatal care, which is essential for a healthy pregnancy outcome. Explanation for why other choices are incorrect: A: Avoiding exercise completely is not recommended during pregnancy, as moderate exercise is beneficial for both the mother and the baby. B: While staying hydrated and resting when tired are important, they do not solely indicate effective prenatal education. C: Eating for two is a common misconception; the focus should be on a balanced diet rather than overeating.

Correct Answer: D

Rationale: The correct answer is D: Teach the patient to rise slowly from a sitting or lying position. This response is appropriate because the patient is likely experiencing orthostatic hypotension, which is common during pregnancy due to hormonal changes. Rising slowly helps prevent sudden drops in blood pressure, reducing dizziness and fainting. A: Instructing the patient to avoid standing for long periods does not address the underlying issue of orthostatic hypotension. B: Encouraging increased sodium intake may not be necessary and could potentially have negative effects. C: Recommending frequent naps does not address the immediate problem of orthostatic hypotension when standing up quickly.