A nurse is caring for a laboring person who is in the first stage of labor. What is the priority assessment to perform during this stage?

Correct Answer: A

Rationale: The correct answer is A: monitor vital signs. During the first stage of labor, it is crucial to monitor the laboring person's vital signs to assess for any signs of distress or complications. This includes monitoring blood pressure, pulse rate, respiratory rate, and temperature. By closely monitoring vital signs, the nurse can identify any potential issues early on and take appropriate actions to ensure the safety and well-being of both the laboring person and the baby. Performing a vaginal exam (B) or cervical check (C) may be necessary later in labor but is not the priority assessment during the first stage. Monitoring the fetal heart rate (D) is also important but not the priority over monitoring the laboring person's vital signs.

Correct Answer: B

Rationale: The correct answer is B: administer oxygen. Fetal bradycardia indicates reduced oxygen supply to the fetus, so providing oxygen to the laboring person can help increase oxygen levels for the fetus. This intervention is crucial to prevent further complications. Increasing fluid intake (A) may not address the immediate issue of fetal distress. Monitoring fetal heart rate continuously (C) is important but not the priority when immediate intervention is needed. Placing the laboring person on their left side (D) can help optimize fetal oxygenation, but administering oxygen is more direct and effective in this situation.

Correct Answer: A

Rationale: The correct answer is A: apply lanolin cream. Lanolin cream helps to soothe and moisturize the nipples, reducing pain and promoting healing. It is safe for the baby and does not need to be removed before breastfeeding. Applying analgesics (B) is not recommended as they can be harmful to the baby. Warm compresses (C) may not provide the same level of relief for nipple pain as lanolin cream. Cold compresses (D) are not suitable for relieving nipple pain as they can further exacerbate discomfort. Therefore, applying lanolin cream is the best intervention for relieving nipple pain during breastfeeding.

Correct Answer: A

Rationale: The correct answer is A: apply gentle downward pressure. This intervention helps prevent rapid expulsion of the baby, reducing the risk of perineal tears and minimizing maternal discomfort. It also helps control the delivery process, ensuring a safe and controlled birth. Incorrect Choices: B: Perineal massage is not indicated at the crowning stage as it may interfere with the natural birthing process. C: Administering pain relief should have been addressed earlier in labor and is not a priority at this stage. D: Administering IV fluids is important for hydration but is not the most critical intervention when the fetal head is crowning.

Correct Answer: B

Rationale: The correct answer is B: administer IV fluids. IV fluids help maintain adequate circulating volume, preventing hypovolemia which is a major risk factor for postpartum hemorrhage. This action supports blood pressure and perfusion to reduce the risk of excessive bleeding. Administering oxytocin (A) helps with uterine contraction but does not address the underlying issue of hypovolemia. Administering an epidural (C) is not directly related to preventing postpartum hemorrhage. Fundal massage (D) is important but not the most critical action in reducing the risk of postpartum hemorrhage.