A nurse is caring for a postpartum person during the fourth stage of labor. The nurse is assessing uterine involution to ensure that the uterus is returning to its prepregnancy size and position. Which finding is indicative of normal uterine involution during this stage?

Correct Answer: B

Rationale: The correct answer is B because during the fourth stage of labor, the uterine fundus should be firm and at the level of the umbilicus. This indicates proper involution as the uterus is contracting and reducing in size. Choice A is incorrect as the uterus should not be palpable at the level of the umbilicus during normal involution. Choice C is incorrect as the uterus should not be displaced to the right side of the abdomen. Choice D is incorrect as the uterus should not be above the level of the umbilicus, as this would suggest inadequate involution.

Correct Answer: A

Rationale: The correct answer is A (every 15 minutes) because immediate postpartum assessment is crucial for early detection of complications. Monitoring vital signs every 15 minutes allows for prompt identification of issues like hemorrhage or infection. Choice B (every 30 minutes) may lead to a delayed response to critical changes. Choice C (once, then hourly) may miss rapid changes in the first hour. Choice D (once, then every 4 hours) is too infrequent for the critical postpartum period. Regular monitoring is essential for ensuring maternal safety.

Correct Answer: C

Rationale: The correct answer is C: to assess fetal heart rate accelerations. An NST is used to monitor the baby's heart rate and movement to ensure adequate oxygen supply. Fetal heart rate accelerations indicate a healthy, responsive baby. Assessing heart rate variability (A) is important but not the primary purpose. Evaluating fetal well-being (B) is broad and doesn't capture the specific focus on heart rate accelerations. Assessing maternal well-being (D) is not the purpose of an NST.

Correct Answer: A

Rationale: The correct answer is A: apply gentle pressure to the fetal head. This action helps prevent rapid delivery, reducing the risk of perineal tearing and promoting controlled delivery of the baby. Applying pressure also helps prevent the baby from being born too quickly, reducing the risk of umbilical cord compression and potential birth injuries. Choices B, C, and D are incorrect because at the moment the head crowns, the priority is to assist with the controlled delivery of the baby's head. Delivering the placenta (B) and assisting with shoulder delivery (C) are steps that come after the baby's head is delivered. Applying pressure to the perineum (D) is not recommended as it may increase the risk of perineal tearing.

Correct Answer: A

Rationale: The primary purpose of performing an episiotomy during delivery is to reduce the risk of perineal trauma. Episiotomy is a surgical incision made in the perineum to widen the vaginal opening during childbirth, which can help prevent severe tearing of the perineal tissue. This procedure is performed to provide controlled and precise incision, reducing the likelihood of extensive tears that may lead to complications such as infection or prolonged healing time. It is not done to promote faster delivery, facilitate fetal descent, or provide immediate fetal oxygenation. These choices do not accurately reflect the main goal of episiotomy, which is to minimize perineal trauma.