A laboring person requests an epidural for pain relief. What is the nurse's priority action before the procedure?

Correct Answer: A

Rationale: The correct answer is A: administer a test dose of anesthesia. Before administering an epidural, it is crucial to perform a test dose to assess the person's response and ensure correct placement of the catheter. This step helps prevent potential complications such as unintentional intravascular injection. Summary: B: Ensuring informed consent is important but not the priority before administering the test dose. C: Administering IV fluids is important for hydration but not the immediate priority before the test dose. D: Continuous fetal monitoring is essential during labor, but it is not the priority before administering the test dose of anesthesia.

Correct Answer: C

Rationale: The correct answer is C, bradycardia. Bradycardia in the fetal heart rate is a significant finding indicating fetal distress because it signifies a heart rate below normal range, which can lead to inadequate oxygen supply to the fetus. Bradycardia can be a sign of fetal hypoxia, acidosis, or other serious conditions. Variable decelerations (choice A) are often caused by umbilical cord compression, late decelerations (choice B) are associated with uteroplacental insufficiency, and accelerations (choice D) are considered a reassuring sign of fetal well-being. Therefore, in the context of fetal distress, bradycardia is the most concerning finding.

Correct Answer: C

Rationale: The correct answer is C: apply oxygen via mask. This is the primary nursing action for a ruptured uterus because it helps improve oxygenation to the laboring person and the fetus. Ruptured uterus can lead to a significant decrease in oxygen supply, so providing oxygen is crucial. Incorrect choices: A: preparing for an emergency cesarean section is important but not the primary action in this situation. B: providing pain relief is important, but ensuring oxygenation is a higher priority. D: applying pressure to the abdomen is not recommended as it can worsen the condition.

Correct Answer: A

Rationale: The correct answer is A: encourage the person to use a peri-bottle. This is crucial for maintaining perineal hygiene and preventing infection after childbirth. Using a peri-bottle helps keep the perineal area clean without causing irritation. Explanation of why the other choices are incorrect: B: Educating on wound care is important but not the most critical teaching point as keeping the area clean with a peri-bottle is the priority. C: Kegel exercises are beneficial for pelvic floor muscles but are not directly related to perineal care. D: Avoiding tampons is important to prevent infection, but using a peri-bottle for hygiene is more immediate and necessary postpartum.

Correct Answer: C

Rationale: The correct answer is C: apply petroleum jelly to the skin. Petroleum jelly acts as a barrier, protecting the baby's skin from moisture and irritants in the diaper. It helps maintain the skin's natural moisture and prevents diaper rash. Rationale: 1. Petroleum jelly creates a protective barrier on the skin, preventing direct contact with moisture and irritants. 2. It helps to keep the skin moisturized, reducing the risk of irritation. 3. Petroleum jelly is safe and gentle on the baby's skin. 4. It is particularly effective for preventing diaper rash compared to other options. Summary: A: Frequent diaper changes are important but may not provide enough protection against moisture and irritants. B: Barrier creams can be effective, but petroleum jelly is a more commonly recommended option. D: Changing diapers frequently is essential, but applying petroleum jelly as an additional protective measure is more effective in preventing diaper rash.