A nurse is assisting with a vaginal birth and notices a prolapsed umbilical cord. What is the immediate nursing action?

Correct Answer: A

Rationale: The correct immediate nursing action for a prolapsed umbilical cord is to administer oxygen via mask (Choice A). This is crucial to ensure adequate oxygenation to the fetus as the prolapsed cord can compress and compromise blood flow. Administering oxygen helps maintain fetal oxygenation until emergency measures can be taken. Placing the person in the knee-chest position (Choice B) is contraindicated as it can further compress the cord. Repositioning the laboring person (Choice C) may not effectively relieve pressure on the cord. While preparing for an emergency delivery (Choice D) is important, administering oxygen is the priority to ensure fetal well-being.

Correct Answer: D

Rationale: The correct answer is D: ensure proper positioning for the vaccine. It is essential to ensure the person is in the correct position before administering the vaccine to ensure accurate and safe administration. Proper positioning helps prevent injury and ensures the vaccine is administered correctly. Verifying the person's immunization history (choice A) is important but not the priority before administering the vaccine. Informed consent (choice B) should be obtained but is not the priority action in this scenario. Checking for signs of an allergic reaction (choice C) is important but should be done after ensuring proper positioning for the vaccine.

Correct Answer: B

Rationale: The correct answer is B because during the second stage of labor, the primary purpose of a vaginal examination is to evaluate uterine progress. This is important to determine the effectiveness of contractions and the progression of labor. Assessing fetal descent (A) is typically done during the first stage of labor. Assessing cervical dilation (C) is important throughout labor but is not the primary purpose during the second stage. Assessing fetal position (D) can also be important but is not the primary focus during the second stage.

Correct Answer: B

Rationale: The correct answer is B: feeling hopeless. Postpartum depression is a serious condition that can lead to feelings of hopelessness, helplessness, and worthlessness. This is concerning as it may indicate a deeper level of despair and potential suicidal ideation. Feeling overwhelmed (choice A) is common in new parents but not necessarily indicative of postpartum depression. Low energy and fatigue (choice C) can be symptoms of depression but are not the most concerning sign. Feeling elated (choice D) is not characteristic of postpartum depression but may indicate other mood disorders.

Correct Answer: B

Rationale: The correct answer is B: apply cold compresses. Cold compresses help reduce inflammation and numb the area, providing pain relief for sore nipples. Warm compresses can worsen pain by increasing blood flow. Distraction techniques do not address the root cause of nipple pain. Lanolin cream is commonly used for nipple pain, but it may not provide immediate relief like cold compresses. Cold compresses are the most appropriate intervention in this situation.