A nurse is assisting with a vaginal birth. What is the most appropriate nursing action when the head crowns during delivery?

Correct Answer: A

Rationale: The correct answer is A: apply gentle pressure to the fetal head. This action helps prevent rapid delivery, reducing the risk of perineal tearing and promoting controlled delivery of the baby. Applying pressure also helps prevent the baby from being born too quickly, reducing the risk of umbilical cord compression and potential birth injuries. Choices B, C, and D are incorrect because at the moment the head crowns, the priority is to assist with the controlled delivery of the baby's head. Delivering the placenta (B) and assisting with shoulder delivery (C) are steps that come after the baby's head is delivered. Applying pressure to the perineum (D) is not recommended as it may increase the risk of perineal tearing.

Correct Answer: D

Rationale: The correct answer is D, instructing the pregnant woman to get up slowly and avoid standing for long periods. This is because during pregnancy, blood pressure can drop when standing up quickly, leading to dizziness and fainting. Getting up slowly allows the body to adjust gradually, preventing a sudden drop in blood pressure. Standing for long periods can worsen these symptoms, so it is important to avoid prolonged standing. A: Lying down flat on the back immediately can worsen symptoms in this case by reducing blood flow to the brain. B: Standing up quickly can exacerbate dizziness and fainting by causing a sudden drop in blood pressure. C: Drinking a large amount of water may not address the underlying issue of postural hypotension and could potentially worsen symptoms by increasing blood volume without addressing the drop in blood pressure.

Correct Answer: A

Rationale: The correct answer is A: provide comfort measures. Comfort measures such as massage, positioning, and relaxation techniques help the laboring person cope with the pain and intensity of contractions. By providing comfort, the nurse can help reduce stress and anxiety, promoting a more positive labor experience. Choice B (assist with breathing exercises) can be helpful, but comfort measures are more essential for overall well-being during labor. Choice C (provide reassurance and comfort) is similar to the correct answer but lacks the specific action of providing comfort measures. Choice D (administer antibiotics) is irrelevant to the management of strong contractions and is not indicated unless there is a specific medical reason for antibiotics.

Correct Answer: B

Rationale: The correct answer is B: Instruct the patient to increase fluid intake and stand slowly. This recommendation is appropriate because the patient is likely experiencing orthostatic hypotension due to the expanding uterus compressing blood vessels, leading to decreased blood flow to the brain when standing. Increasing fluid intake helps maintain blood volume, while standing slowly helps prevent sudden drops in blood pressure. A: Rising quickly can worsen dizziness by further decreasing blood flow to the brain. C: Resting in bed may not address the underlying issue of orthostatic hypotension and may lead to deconditioning. D: Avoiding standing for long periods may be impractical and may not address the need to maintain adequate blood volume and prevent sudden drops in blood pressure.

Correct Answer: A

Rationale: The correct answer is A: Count fetal movements and report a decrease of more than 10 movements per day. This recommendation is evidence-based and aligns with guidelines for monitoring fetal well-being. Counting fetal movements helps assess fetal health, and a decrease in movements could indicate potential issues like fetal distress. Reporting a decrease of more than 10 movements per day ensures timely intervention if needed. Choice B is incorrect because waiting until after 32 weeks could delay necessary intervention if there are concerns about fetal movements. Choice C is incorrect as it dismisses the importance of monitoring fetal movements altogether. Choice D is incorrect as there is no requirement to always lie down or restrict monitoring to only after meals, which could lead to missed opportunities for detecting potential problems.