A nurse is caring for a laboring person who has been pushing for several hours without progress. What is the most appropriate intervention?

Correct Answer: B

Rationale: The correct answer is B: assist with vacuum extraction. This intervention is appropriate when prolonged pushing has not resulted in progress during labor. Vacuum extraction helps facilitate the delivery of the baby by applying suction to the baby's head to assist with pulling them out. It is less invasive than a cesarean section and forceps delivery, making it a safer option in this scenario. Performing a cesarean section (choices A and C) would be considered if vacuum extraction is unsuccessful or contraindicated due to specific factors. Forceps delivery (choice D) is another option but is generally considered more invasive and carries higher risks compared to vacuum extraction.

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: proper positioning. Proper positioning is crucial for successful breastfeeding as it ensures the baby latches on effectively, leading to efficient milk transfer and preventing nipple pain or damage. Incorrect answers: A: frequent breastfeeding - While important, proper positioning is more critical for successful breastfeeding. C: supportive communication - While important for overall well-being, it is not the most crucial factor for successful breastfeeding. D: promote rest and hydration - While important for the postpartum person's health, proper positioning is key for successful breastfeeding.

Correct Answer: B

Rationale: The correct answer is B: Spinal headache. Postpartum spinal headaches are commonly caused by leakage of cerebrospinal fluid due to accidental dural puncture during epidural anesthesia. This can lead to severe headaches that worsen when sitting or standing. Eclampsia (A) presents with hypertension and seizures, not just headaches. Tension headaches (C) are typically stress-related and not specific to the postpartum period. Cluster headaches (D) are characterized by severe pain around the eye and are not commonly associated with childbirth.

Correct Answer: A

Rationale: The correct answer is A: Monitor vital signs. This is the most important intervention because changes in vital signs can indicate the presence of infection early on. By closely monitoring the postpartum person's vital signs, the nurse can promptly identify any signs of infection and initiate appropriate interventions. Educating on proper hygiene (B) and wound care (C) are essential but monitoring vital signs takes precedence in immediate infection detection. Encouraging ambulation (D) is beneficial for preventing complications like blood clots, but it is not the most crucial intervention for infection prevention in this scenario.