A nurse is monitoring a postpartum person for signs of infection. Which finding would be most concerning in the first 24 hours after delivery?

Correct Answer: A

Rationale: The correct answer is A: fever. A fever in the first 24 hours after delivery is most concerning as it may indicate an infection, such as endometritis, which can lead to serious complications if not promptly treated. Postpartum fever is often the earliest sign of infection due to retained products of conception or ascending genital tract infection. Monitoring for fever is crucial as it can help prevent sepsis. Foul-smelling lochia (choice B) may suggest infection but is not as immediate a concern as fever. Increased blood pressure (choice C) and heart rate (choice D) may be normal physiological responses to delivery and are not specific indicators of infection in the immediate postpartum period.

Correct Answer: D

Rationale: The correct answer is D: prepare the person for a blood transfusion. Meconium-stained amniotic fluid indicates fetal distress, which can lead to hypoxia and potential blood loss in the laboring person. The priority action is to prepare for a potential blood transfusion to address any hemorrhage that may occur during delivery. This is crucial for ensuring the safety and well-being of both the laboring person and the baby. Incorrect options: A: Prepare for an emergency cesarean section - While meconium-stained amniotic fluid may indicate fetal distress, the priority is addressing potential maternal blood loss. B: Document the amount of meconium - Documenting is important but not the priority when the person's health is at risk. C: Notify the healthcare provider - While important, immediate action to address potential blood loss takes precedence over notifying the healthcare provider.

Correct Answer: A

Rationale: The correct answer is A: administer a preoperative medication. This is crucial prior to an emergency cesarean birth to ensure the person is adequately prepared for the procedure. Preoperative medications can help reduce anxiety, prevent complications such as aspiration during anesthesia induction, and promote smooth recovery post-surgery. Administering pain relief (B) and epidural block (C) may be important for comfort but are not the priority in this urgent situation. Administering IV fluids (D) is generally important in preparation for surgery, but administering preoperative medication takes precedence in this scenario to ensure the person's safety and well-being during the emergency cesarean birth.

Correct Answer: A

Rationale: The correct answer is A: place the person on their left side. This intervention helps to optimize placental perfusion and reduce pressure on the vena cava, improving fetal oxygenation. Late decelerations indicate uteroplacental insufficiency, and changing the person's position can help alleviate this. Applying oxygen via mask (B) is important but secondary to optimizing perfusion. Administering pain medication (C) is not the priority in this situation. Performing a vaginal examination (D) is unnecessary and could potentially worsen the situation.

Correct Answer: C

Rationale: The correct answer is C: No voiding for several hours. Postpartum urinary retention is common due to trauma during childbirth. The bladder may be unable to contract effectively, leading to a lack of sensation to void. This can result in no voiding for several hours. Abdominal distension (A) is not specific to urinary retention. Frequent voiding (B) and urinary urgency (D) are not characteristic signs of urinary retention; they are more indicative of overactive bladder or urinary tract infection.