A nurse is caring for a laboring person who is in the second stage of labor. What is the most appropriate nursing intervention during the pushing phase?

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: A

Rationale: The correct answer is A: encourage ambulation. Walking during the first stage of labor can help facilitate the descent of the fetus, promote optimal positioning, and enhance comfort by utilizing gravity to aid in the progression of labor. Ambulation also encourages blood circulation and may provide a distraction from discomfort. Administering pain medication (B) is not the initial intervention in promoting relaxation and comfort during early labor. Providing distraction and breathing techniques (C) may be beneficial, but ambulation is more effective in promoting relaxation. Offering relaxation techniques (D) is helpful, but encouraging movement through ambulation is a more active approach in easing discomfort and promoting relaxation during the first stage of labor.

Correct Answer: A

Rationale: The correct answer is A: notify the healthcare provider. This is the most appropriate action because the presence of meconium in the amniotic fluid indicates potential fetal distress, requiring immediate medical evaluation. Notifying the healthcare provider allows for prompt assessment and necessary interventions to ensure the well-being of both the laboring person and the baby. Documenting the amount of meconium (choice B) may be important for the medical record but is not the priority in this situation. Choices C and D, preparing for vacuum extraction and applying pressure to the abdomen, are not indicated and could potentially harm the baby or the laboring person.

Correct Answer: A

Rationale: The correct answer is A: administer anticoagulants. Anticoagulants help prevent blood clots, reducing the risk of thrombophlebitis. Administering anticoagulants is the most effective intervention for someone at risk. Applying compression stockings (B) can help with circulation but may not be sufficient for someone at high risk. Using a footstool (C) can promote circulation but is not as direct as anticoagulants. Monitoring for signs of DVT (D) is important but not as proactive as administering anticoagulants for prevention.

Correct Answer: A

Rationale: The correct answer is A: apply gentle downward pressure. This intervention helps prevent rapid delivery to avoid perineal tearing and allows controlled stretching of the perineum. Applying upward pressure (B) can increase the risk of tearing. Positioning (C) is important but not the most critical at this stage. Perineal massage (D) is typically done before crowning, not during.