A nurse is caring for a laboring person who is receiving oxytocin for labor induction. What is the priority intervention when uterine hyperstimulation occurs?

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: 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.

Correct Answer: A

Rationale: The correct answer is A: monitor fetal heart rate. During the first stage of labor, assessing the fetal heart rate is crucial to ensure the well-being of the baby. It helps detect any signs of distress or complications early on. Monitoring the mother's health is also important, but ensuring the baby's safety takes precedence. Assessing cervical dilation (B) is important but not the priority in the early stage. Assisting with positioning (C) can help progress labor but is secondary to monitoring fetal well-being. Administering an epidural (D) is not a priority assessment but a pain management intervention.

Correct Answer: B

Rationale: The correct answer is B: offer pain relief. Providing pain relief is crucial in preventing nipple trauma as it can help the postpartum person tolerate any discomfort associated with breastfeeding, thereby reducing the likelihood of damage to the nipples. Assisting with breastfeeding positioning (choice A) is important but not as critical as pain relief. Applying a cold compress (choice C) may help with inflammation but does not directly address the pain during breastfeeding. Monitoring contractions (choice D) is unrelated to preventing nipple trauma. Ultimately, addressing pain relief is the most effective intervention in ensuring successful and comfortable breastfeeding, thus preventing nipple trauma.