A nurse is assessing a laboring person and notes the presence of meconium-stained amniotic fluid. What is the priority nursing action?

Correct Answer: D

Rationale: The correct answer is D: prepare the person for a blood transfusion. Meconium-stained amniotic fluid indicates fetal distress, which can lead to hypoxia and potential blood loss in the laboring person. The priority action is to prepare for a potential blood transfusion to address any hemorrhage that may occur during delivery. This is crucial for ensuring the safety and well-being of both the laboring person and the baby. Incorrect options: A: Prepare for an emergency cesarean section - While meconium-stained amniotic fluid may indicate fetal distress, the priority is addressing potential maternal blood loss. B: Document the amount of meconium - Documenting is important but not the priority when the person's health is at risk. C: Notify the healthcare provider - While important, immediate action to address potential blood loss takes precedence over notifying the healthcare provider.

Correct Answer: A

Rationale: The correct answer is A: place the person on their left side. This intervention helps to optimize placental perfusion and reduce pressure on the vena cava, improving fetal oxygenation. Late decelerations indicate uteroplacental insufficiency, and changing the person's position can help alleviate this. Applying oxygen via mask (B) is important but secondary to optimizing perfusion. Administering pain medication (C) is not the priority in this situation. Performing a vaginal examination (D) is unnecessary and could potentially worsen the situation.

Correct Answer: C

Rationale: The correct answer is C: No voiding for several hours. Postpartum urinary retention is common due to trauma during childbirth. The bladder may be unable to contract effectively, leading to a lack of sensation to void. This can result in no voiding for several hours. Abdominal distension (A) is not specific to urinary retention. Frequent voiding (B) and urinary urgency (D) are not characteristic signs of urinary retention; they are more indicative of overactive bladder or urinary tract infection.

Correct Answer: B

Rationale: The correct answer is B because in the second stage of labor, it is appropriate to assist the laboring person with spontaneous pushing to facilitate the descent of the baby through the birth canal. Controlled pushing (choice A) may cause fatigue and unnecessary strain. Deep breathing (choice C) is more suitable for the first stage of labor. Non-pharmacological pain relief (choice D) can be helpful but is not the priority in the second stage when the focus should be on pushing effectively.

Correct Answer: A

Rationale: The correct answer is A: coach the person through controlled pushing. This is the most important action to promote fetal descent during the second stage of labor because pushing helps the baby move through the birth canal. Controlled pushing helps prevent exhaustion and reduces the risk of maternal injury. Increasing maternal hydration (choice B) is important for overall well-being but does not directly promote fetal descent. Comfort measures (choice C) are important for pain management but do not directly aid in fetal descent. Applying gentle pressure to the abdomen (choice D) is not recommended as it can interfere with the natural process of labor.