A nurse is preparing a laboring person for a cesarean birth. What is the most important action the nurse should take prior to the procedure?

Correct Answer: A

Rationale: The correct answer is A: administer a preoperative medication. This is the most important action because it helps prepare the laboring person for the cesarean birth by ensuring they are adequately medicated for the procedure. Administering preoperative medication can help reduce anxiety, manage pain, and ensure the person is in a suitable condition for surgery. Summary of other choices: B: Assisting with positioning the person is important but not the most critical action before a cesarean birth. C: Performing a cesarean section is not a nursing responsibility and is done by the healthcare provider. D: Monitoring fetal heart tones is important but not the most crucial action for preparing the laboring person for a cesarean birth.

Correct Answer: B

Rationale: The correct answer is B: prepare the person for a cesarean section. In the scenario of vacuum extraction, if there are complications or the procedure is unsuccessful, the person may need to undergo an emergency cesarean section. By preparing the person for this possibility, the nurse ensures timely intervention if needed, prioritizing the safety of both the person and the baby. Monitoring fetal heart rate continuously (A) is important but not the most crucial action in this case. Monitoring for signs of uterine rupture (C) is not directly related to vacuum extraction. Assisting with positioning (D) is important but not as critical as preparing for a potential cesarean section.

Correct Answer: B

Rationale: The correct answer is B: check for any contraindications. Before administering an epidural, it is crucial to assess for contraindications such as low platelet count, infection at the insertion site, or severe hypotension as these may increase the risk of complications. Administering an epidural bolus (A) without checking for contraindications can be dangerous. Performing a vaginal exam (C) is not necessary before an epidural and could increase the risk of infection. Ensuring continuous fetal monitoring (D) is important during labor but is not the most critical action before administering an epidural.

Correct Answer: A

Rationale: The correct answer is A: Administer tocolytics. Tocolytics help to inhibit uterine contractions and can be used to address irregular contractions during labor. This intervention helps to prevent preterm labor and promote fetal well-being. Administering analgesics (choice B) may help with pain management but does not address the underlying issue of irregular contractions. Monitoring fetal heart rate (choice C) is important but does not directly address the irregular contractions. Increasing oxytocin infusion (choice D) would worsen the situation by further stimulating contractions. Therefore, administering tocolytics is the priority intervention to address irregular contractions during labor.

Correct Answer: C

Rationale: The correct answer is C: offer antibiotics as needed. In postpartum individuals at high risk for infection, antibiotics may be necessary to prevent or treat infections. Antibiotics target specific pathogens, reducing the risk of infection. Proper hand hygiene (B) and infection control practices (D) are important but do not directly address the underlying risk of infection. Providing perineal care and hygiene (A) is essential for overall hygiene but may not be sufficient in preventing infections in high-risk individuals. Antibiotics, when prescribed judiciously and appropriately, can be crucial in reducing the risk of infection and promoting recovery.