A nurse is assessing a laboring person's progress. What is the most reliable indicator that the laboring person is in the active phase of labor?

Correct Answer: A

Rationale: The correct answer is A: Progressive cervical dilation. This is the most reliable indicator of the active phase of labor because it directly reflects the opening of the cervix, indicating that labor is advancing. Cervical dilation is a key aspect of labor progress and is used to determine the stage of labor. Frequent, regular contractions (choice B) are important but can occur in early labor as well. Fetal descent (choice C) is an important aspect but may happen in conjunction with cervical dilation. Effacement of the cervix (choice D) is also important but does not solely indicate the active phase of labor.

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.

Correct Answer: A

Rationale: The correct answer is A: monitor vital signs. During the first stage of labor, it is crucial to monitor the laboring person's vital signs to assess for any signs of distress or complications. This includes monitoring blood pressure, pulse rate, respiratory rate, and temperature. By closely monitoring vital signs, the nurse can identify any potential issues early on and take appropriate actions to ensure the safety and well-being of both the laboring person and the baby. Performing a vaginal exam (B) or cervical check (C) may be necessary later in labor but is not the priority assessment during the first stage. Monitoring the fetal heart rate (D) is also important but not the priority over monitoring the laboring person's vital signs.