A nurse is caring for a postpartum person who is breastfeeding. What is the most appropriate intervention if the person is experiencing nipple pain?

Correct Answer: B

Rationale: The correct answer is B: apply cold compresses. Cold compresses help reduce inflammation and numb the area, providing pain relief for sore nipples. Warm compresses can worsen pain by increasing blood flow. Distraction techniques do not address the root cause of nipple pain. Lanolin cream is commonly used for nipple pain, but it may not provide immediate relief like cold compresses. Cold compresses are the most appropriate intervention in this situation.

Correct Answer: C

Rationale: The correct answer is C: pale skin. This is because the most common early sign of postpartum hemorrhage is hypovolemia, which leads to decreased perfusion and oxygenation of tissues. Pale skin indicates decreased blood flow and oxygen delivery, a key indicator of hypovolemia. Excessive bleeding (choice A) is a symptom, not a sign. Low blood pressure (choice B) is a late sign of postpartum hemorrhage. Dark red bleeding (choice D) may indicate the presence of clots but is not specific to early postpartum hemorrhage.

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: B

Rationale: The correct answer is B: tachycardia. Fetal distress is often indicated by an increased fetal heart rate, known as tachycardia. This can be a sign of the fetus not receiving enough oxygen. Bradycardia (choice C) is a lower heart rate and not typically associated with fetal distress. Irregular fetal heart rate (choice D) may also indicate distress, but tachycardia is more commonly observed. Increasing oxygen flow (choice A) is a potential intervention for fetal distress but not a sign of distress itself. In summary, tachycardia is the most common sign of fetal distress due to potential oxygen deprivation.

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.