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

Correct Answer: A

Rationale: The correct answer is A: assist with the delivery of the placenta. During the third stage of labor, the placenta needs to be delivered. This is done by gently applying traction to the umbilical cord while supporting the uterus to facilitate the expulsion of the placenta. This step is crucial to prevent postpartum hemorrhage. Choice B (prepare for a vaginal birth) is incorrect because the person is already in the third stage of labor, which means the baby has been delivered and they are now focusing on delivering the placenta. Choice C (administer oxytocin) is incorrect because while oxytocin may be used to help control bleeding after the placenta is delivered, it is not the most appropriate intervention during the third stage of labor. Choice D (apply gentle pressure to the uterus) is incorrect because direct pressure to the uterus is not the primary intervention during the third stage of labor; assisting with the delivery of the placenta takes precedence.

Correct Answer: D

Rationale: The correct answer is D: administer an epidural. Uterine hyperstimulation during labor can lead to fetal distress and complications. Administering an epidural can help manage pain and relax the uterus, reducing the risk of hyperstimulation. Stopping the oxytocin infusion (choice A) is also important, but managing the uterine contractions with an epidural takes priority. Increasing the oxytocin infusion (choice B) would exacerbate the hyperstimulation. Administering IV fluids (choice C) may be helpful, but it does not directly address the uterine hyperstimulation.

Correct Answer: C

Rationale: The correct answer is C: administer IV fluids. Before a cesarean birth, IV fluids are crucial to maintain hydration and prevent hypotension due to anesthesia. Administering IV fluids helps stabilize the person's blood pressure during the procedure, reducing the risk of complications. A is incorrect because informed consent should be obtained earlier in the process. B is incorrect as preoperative medication is typically given closer to the procedure start time. D is incorrect as administering a sedative may affect the person's ability to participate in decision-making and care during the procedure. Administering IV fluids is the priority to ensure the person's safety and well-being during the cesarean birth.

Correct Answer: B

Rationale: The correct answer is B: perform fundal massage. Fundal massage helps stimulate uterine contractions and prevents uterine atony by promoting uterine firmness and reducing the risk of excessive bleeding. It is a non-invasive intervention that can be done immediately after delivery to prevent postpartum hemorrhage. Administering uterotonic medications (Choice A) may be necessary in severe cases but fundal massage is the initial intervention. Performing a vaginal exam (Choice C) is not indicated unless there are specific concerns or indications. Monitoring vital signs (Choice D) is important but addressing uterine atony requires more direct intervention like fundal massage.

Correct Answer: A

Rationale: Correct Answer: A: Administer oxygen Rationale: Fetal tachycardia indicates the fetus is not getting enough oxygen. Administering oxygen to the laboring person will help increase oxygen levels in their blood, leading to better oxygen supply to the fetus and potentially improving the fetal heart rate. Summary of Other Choices: B: Administering IV fluids may be helpful in some cases, but it is not the priority when dealing with fetal tachycardia. C: While monitoring maternal vital signs is important, addressing the fetal tachycardia and oxygen supply to the fetus takes precedence. D: Continuous monitoring of fetal heart rate is essential, but administering oxygen should be the immediate intervention to address the underlying issue of oxygen deficiency.