A nurse is caring for a laboring person who is receiving an epidural. What is the most important nursing intervention when administering an epidural?

Correct Answer: A

Rationale: The correct answer is A: Ensure the person is positioned correctly. This is crucial because proper positioning ensures the medication is distributed correctly and helps prevent complications like uneven distribution or nerve injury. Monitoring blood pressure (B) and oxygen saturation (C) are important but secondary to ensuring correct positioning. Administering pain medication (D) is not a nursing intervention specific to epidural administration.

Correct Answer: C

Rationale: The correct answer is C: to monitor maternal vital signs. During labor, monitoring maternal vital signs such as blood pressure, heart rate, and oxygen saturation is crucial to ensure the well-being of both the mother and the baby. Changes in these vital signs can indicate potential complications that may require immediate intervention. Fetal heart rate variability (A) is important but not the primary purpose of using a fetal monitor. Monitoring for fetal distress (B) is indeed important, but the primary purpose is to ensure the mother's health. Assessing the mother's emotional state (D) is not the primary reason for using a fetal monitor during labor.

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.