A nurse is caring for a laboring person who is experiencing strong contractions. What is the most important intervention to support the laboring person during this time?

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: 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.

Correct Answer: A

Rationale: The correct answer is A: Ensure informed consent is signed. Before any procedure, it is crucial to obtain informed consent to ensure the individual understands the risks, benefits, and alternatives. This protects their autonomy and ensures they are making an informed decision. Administering IV fluids (B) is important but not as critical as obtaining consent. Monitoring vital signs (C) is essential but not the most important step before the procedure. Administering pain relief (D) should only be done after ensuring informed consent and assessing the individual's pain level.

Correct Answer: A

Rationale: The correct answer is A: apply gentle downward pressure. This action helps prevent the baby from being born too quickly, reducing the risk of tearing for the mother. It also ensures a controlled delivery, decreasing the likelihood of complications such as shoulder dystocia. Administering pain relief (B) or analgesics (C) may be necessary but not the most crucial at this moment. Performing perineal massage (D) is beneficial for reducing the risk of tearing but is not as important as guiding the baby's head during crowning.