A nurse is preparing a laboring person for an epidural block. What is the nurse's priority action before the procedure?

Correct Answer: A

Rationale: The correct answer is A: ensure the birthing person is positioned correctly. This is the priority action because proper positioning is crucial for the safe and effective administration of an epidural block. Incorrect positioning can lead to complications such as inadequate pain relief, nerve damage, or difficulty in performing the procedure. Checking for allergies to anesthesia (B) is important but not the priority before positioning. Administering a test dose of anesthesia (C) should only be done after ensuring correct positioning. Administering IV fluids (D) is important but not the priority action before positioning.

Correct Answer: B

Rationale: The correct answer is B: perform uterine massage. This intervention aims to prevent excessive bleeding and stabilize the uterus. Uterine massage helps to maintain uterine tone, which is crucial in managing uterine rupture. This intervention can help reduce the risk of maternal hemorrhage and improve fetal oxygenation. Incorrect choices: A: Emergency cesarean section may be necessary but is not the priority as immediate measures to control bleeding and maintain uterine tone are crucial. C: Applying pressure to the abdomen is not recommended as it can further exacerbate uterine rupture and increase the risk of complications. D: Continuous monitoring of the fetal heart rate is important but not the priority in managing uterine rupture, which requires immediate intervention to prevent maternal and fetal complications.

Correct Answer: B

Rationale: The correct answer is B: monitor fetal heart rate continuously. This is crucial because oxytocin can cause uterine hyperstimulation leading to fetal distress. Continuous monitoring allows for early detection of fetal compromise. Monitoring for signs of uterine hyperstimulation (A) is important but secondary to fetal well-being. Emotional support (C) and encouraging ambulation (D) are beneficial but not as critical as ensuring fetal safety during oxytocin administration.

Correct Answer: C

Rationale: The correct answer is C: assess uterine tone. This is the priority assessment during oxytocin infusion because oxytocin can cause uterine hyperstimulation, leading to fetal distress. By assessing uterine tone regularly, the nurse can detect any signs of hyperstimulation early and take appropriate action to prevent complications. Monitoring fetal heart rate (A) is important but assessing uterine tone takes precedence as it directly impacts fetal well-being. Maternal vital signs (B) are important but are not as directly related to the safety of the fetus during oxytocin infusion. Monitoring for signs of uterine hyperstimulation (D) is essential, but assessing uterine tone is the proactive approach to detect hyperstimulation before it escalates.

Correct Answer: B

Rationale: The correct initial action is to monitor blood pressure (B) because postpartum headache could indicate preeclampsia, a serious condition characterized by high blood pressure. Monitoring blood pressure is crucial to assess for signs of preeclampsia. Administering pain medication (A) may mask symptoms, performing a neurological assessment (C) may not address the underlying cause, and providing oxygen (D) is not the priority without knowing the cause of the headache.