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

Correct Answer: A

Rationale: The correct answer is A: assess fetal heart rate. During the first stage of labor, monitoring the fetal heart rate is crucial as it indicates the well-being of the baby. Changes in fetal heart rate can signal distress and prompt intervention. Monitoring contractions is important but assessing fetal well-being takes precedence. Checking blood pressure is important but not the most critical in this stage. Assisting with breathing exercises can help manage pain, but assessing fetal heart rate is more crucial for ensuring the baby's safety.

Correct Answer: C

Rationale: The correct answer is C: decreased fetal movement. Uterine rupture can lead to decreased blood flow to the fetus, resulting in reduced fetal movement. This sign is crucial as it indicates fetal distress and the need for immediate medical intervention. Abdominal pain (A) can be present but is not specific to uterine rupture. Vaginal bleeding (B) is a sign of placental abruption, not uterine rupture. Increased fetal heart rate (D) can occur due to fetal distress, but decreased fetal movement is a more direct sign of uterine rupture.

Correct Answer: A

Rationale: The correct answer is A: apply lanolin cream. Lanolin cream helps soothe and moisturize sore nipples, providing relief during breastfeeding. It is safe for both the mother and the baby. Applying lanolin cream after each feeding can prevent further irritation and promote healing. Incorrect choices: B: Administering IV fluids is not indicated for sore nipples. C: Performing uterine massage is unrelated to treating sore nipples. D: Applying cold compress may provide temporary relief but does not address the underlying issue of sore nipples.

Correct Answer: B

Rationale: The correct answer is B: administer analgesics. Pain management is crucial to promote effective breastfeeding as it can help the postpartum person be more comfortable and relaxed during breastfeeding sessions. This can lead to better latch and milk transfer, ultimately enhancing the breastfeeding experience. A: assist with positioning - While positioning is important for successful breastfeeding, it is not the most crucial action compared to pain management. C: administer IV fluids - IV fluids are not directly related to promoting effective breastfeeding. Hydration is important but not the most critical factor in this scenario. D: assist with breastfeeding positioning - This choice is similar to option A and while important, it is not as critical as ensuring proper pain management for effective breastfeeding.

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.