A nurse is assessing the fetal heart rate of a laboring person. What is the most significant finding that would indicate fetal distress?

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: 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.

Correct Answer: B

Rationale: The correct answer is B, to increase fetal monitoring. This is crucial to assess the fetal well-being and identify any potential distress or complications early on. Monitoring allows for timely interventions to be implemented to optimize outcomes. Increasing oxygen flow (A) may be necessary in some cases, but it is not the initial priority. Administering an analgesic (C) may help with pain management but does not address the fetal heart rate patterns. Increasing fluid intake (D) is important for hydration but is not directly related to managing fetal heart rate patterns.