A nurse is caring for a birthing person who is experiencing a late deceleration in fetal heart rate. What is the most appropriate action for the nurse to take?

Correct Answer: A

Rationale: The correct action for a nurse when a birthing person experiences late deceleration in fetal heart rate is to turn the laboring person to the left side. This helps improve placental perfusion by reducing pressure on the vena cava, enhancing blood flow to the uterus, and thus improving oxygenation to the fetus. This action can help alleviate the late deceleration and prevent fetal distress. Increasing maternal oxygen supply (choice B) is important but not the first-line intervention for late decelerations. Emergency cesarean section (choice C) is not typically indicated for late decelerations unless other interventions fail. Administering terbutaline (choice D) is not appropriate for late decelerations as it is a tocolytic used to inhibit uterine contractions and prevent preterm labor.

Correct Answer: A

Rationale: The primary goal of using an epidural during labor is to provide analgesia without sedation. Epidurals block pain signals, allowing the laboring individual to feel relief while remaining fully conscious. This helps manage labor pain effectively without causing sedation, allowing the individual to actively participate in the birthing process. Choice B is incorrect because epidurals can limit movement and positioning due to numbness. Choice C is incorrect as the main purpose is pain relief, not anxiety relief. Choice D is incorrect as continuous monitoring can be achieved through other methods, and it is not the primary goal of using an epidural.

Correct Answer: A

Rationale: The correct answer is A: Ensure the person is positioned correctly. This is crucial because proper positioning ensures the medication is distributed correctly and helps prevent complications like uneven distribution or nerve injury. Monitoring blood pressure (B) and oxygen saturation (C) are important but secondary to ensuring correct positioning. Administering pain medication (D) is not a nursing intervention specific to epidural administration.

Correct Answer: D

Rationale: The correct answer is D: prepare for spontaneous delivery. During the pushing phase of the second stage of labor, the most appropriate nursing intervention is to prepare for the spontaneous delivery of the baby. This involves ensuring that all necessary equipment and supplies are ready for the delivery, positioning oneself appropriately to assist with the birth, and being prepared to provide immediate care to the newborn. This intervention is crucial to ensure a safe and smooth delivery process. Choice A (assist the person into a squatting position) may not be appropriate for all laboring individuals and may not facilitate the most effective pushing efforts. Choice B (instruct the person to push with contractions) is a general instruction that may not encompass all the necessary aspects of supporting the delivery process. Choice C (coach the person through controlled pushing) may be too restrictive and not allow for the natural progression of labor. Thus, the most appropriate intervention is to prepare for spontaneous delivery to ensure readiness and safety for both the laboring person and the newborn.

Correct Answer: C

Rationale: The correct answer is C: to monitor maternal vital signs. During labor, monitoring maternal vital signs such as blood pressure, heart rate, and oxygen saturation is crucial to ensure the well-being of both the mother and the baby. Changes in these vital signs can indicate potential complications that may require immediate intervention. Fetal heart rate variability (A) is important but not the primary purpose of using a fetal monitor. Monitoring for fetal distress (B) is indeed important, but the primary purpose is to ensure the mother's health. Assessing the mother's emotional state (D) is not the primary reason for using a fetal monitor during labor.