A nurse is monitoring a laboring person's vital signs during the first stage of labor. Which vital sign change is most likely to indicate the need for further evaluation?

Correct Answer: B

Rationale: The correct answer is B, an increase in blood pressure, which is most likely to indicate the need for further evaluation during the first stage of labor. An increase in blood pressure could signal potential complications like preeclampsia or hypertension, which require immediate attention to ensure the safety of both the laboring person and the baby. A: A decrease in heart rate is not typically concerning during the first stage of labor, as it can be a normal response to relaxation or rest periods between contractions. C: An increase in pulse rate is expected during labor as the body works harder, so it may not necessarily indicate a need for further evaluation unless it is excessively high. D: No change in vital signs could be normal, but it is important to monitor for any signs of distress or complications even if vital signs remain stable.

Correct Answer: C

Rationale: Performing an amniotomy during labor is done to augment labor by releasing amniotic fluid, which can help progress labor by increasing uterine contractions and encouraging the descent of the baby's head. This can help prevent prolonged labor and facilitate a smoother delivery process. Options A, B, and D are incorrect because inducing labor, reducing the risk of infection, and preventing fetal infection are not the primary purposes of performing an amniotomy.

Correct Answer: A

Rationale: The primary goal of using an epidural during labor is to provide analgesia without sedation. Epidurals block pain signals, allowing the laboring individual to feel relief while remaining fully conscious. This helps manage labor pain effectively without causing sedation, allowing the individual to actively participate in the birthing process. Choice B is incorrect because epidurals can limit movement and positioning due to numbness. Choice C is incorrect as the main purpose is pain relief, not anxiety relief. Choice D is incorrect as continuous monitoring can be achieved through other methods, and it is not the primary goal of using 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: D

Rationale: The correct answer is D: prepare for spontaneous delivery. During the pushing phase of the second stage of labor, the most appropriate nursing intervention is to prepare for the spontaneous delivery of the baby. This involves ensuring that all necessary equipment and supplies are ready for the delivery, positioning oneself appropriately to assist with the birth, and being prepared to provide immediate care to the newborn. This intervention is crucial to ensure a safe and smooth delivery process. Choice A (assist the person into a squatting position) may not be appropriate for all laboring individuals and may not facilitate the most effective pushing efforts. Choice B (instruct the person to push with contractions) is a general instruction that may not encompass all the necessary aspects of supporting the delivery process. Choice C (coach the person through controlled pushing) may be too restrictive and not allow for the natural progression of labor. Thus, the most appropriate intervention is to prepare for spontaneous delivery to ensure readiness and safety for both the laboring person and the newborn.