A nurse is caring for a laboring person in the second stage of labor. What is the most appropriate intervention when the perineum starts to bulge?

Correct Answer: B

Rationale: The correct answer is B: apply gentle pressure to the perineum. This intervention helps to support the perineum and reduce the risk of perineal tearing during childbirth. Applying gentle pressure can slow down the baby's descent and allow the perineum to stretch gradually, reducing the likelihood of severe tearing. This intervention is important to promote a safe and controlled delivery. Incorrect answer explanations: A: Applying warm compresses may provide some comfort but does not specifically address the need to support the perineum during childbirth. C: Episiotomy should be considered only when necessary and not as a routine intervention when the perineum bulges. D: Perineal massage is typically done during the prenatal period to help prepare the perineum for childbirth but is not the most appropriate intervention when the perineum starts to bulge during labor.

Correct Answer: A

Rationale: The correct action is to perform uterine massage. This helps to prevent postpartum hemorrhage by promoting uterine contraction and reducing uterine atony. It stimulates the release of endogenous oxytocin, aiding in the expulsion of clots and reducing bleeding. Administering uterotonic medications (choice B) would be the next step if uterine massage alone is ineffective. Perineal massage (choice C) is unrelated to managing a boggy uterus. Administering oral pain relief (choice D) does not address the root cause of the issue.

Correct Answer: A

Rationale: The primary purpose of assessing cervical dilation during labor is to evaluate the progress of labor. Cervical dilation indicates how far the labor has advanced and helps determine if the labor is proceeding normally. Monitoring dilation helps healthcare providers make informed decisions about the timing of interventions and the overall management of labor. It does not directly assess the need for interventions (choice B), complications (choice C), or fetal position (choice D). These factors can be assessed through other means, but the main focus of assessing cervical dilation is to track the progression of labor.

Correct Answer: B

Rationale: The correct answer is B: provide skin-to-skin contact. This is the most appropriate intervention because it promotes bonding, regulates the baby's temperature, and enhances breastfeeding success by stimulating the baby's natural instincts. Assisting with latching (choice A) may be necessary but providing skin-to-skin contact should be prioritized. Educating on breast care (choice C) and postpartum care (choice D) are important, but the immediate need is to establish successful breastfeeding through skin-to-skin contact.

Correct Answer: B

Rationale: The correct answer is B: administer IV fluids. IV fluids help maintain adequate hydration which prevents blood from becoming too thick and reduces the risk of clot formation. Adequate hydration also promotes blood circulation, decreasing the risk of DVT. Administering anticoagulants (choice A) is important in managing DVT but is not the most important preventive intervention. Performing leg exercises (choice C) and ensuring early ambulation (choice D) are also beneficial in preventing DVT, but maintaining hydration with IV fluids is the most crucial intervention as it directly addresses the primary factor contributing to DVT formation.