A nurse is preparing a laboring person for an epidural. What is the most important nursing action prior to the procedure?

Correct Answer: C

Rationale: The correct answer is C: ensure informed consent is obtained. Prior to any medical procedure, including epidural administration, it is crucial to obtain informed consent from the patient. This involves explaining the procedure, risks, benefits, and alternatives to the patient, ensuring they understand and voluntarily agree to the procedure. Without informed consent, the procedure cannot proceed ethically. Choice A (ensure the birthing person is in a sitting position) is not the most important action as the position can be adjusted during the procedure. Choice B (check for allergies to anesthesia) is important but obtaining informed consent takes precedence. Choice D (administer IV fluids) is not a priority before obtaining informed consent.

Correct Answer: B

Rationale: The correct answer is B: Ensure informed consent. This is crucial before any medical procedure, including epidural administration. It ensures the laboring person understands the risks, benefits, and alternatives of the epidural. Proper positioning (choice A) is important during the procedure but not the most critical pre-procedure intervention. Monitoring contractions (choice C) and assisting with breathing (choice D) are important aspects of labor support but not directly related to obtaining informed consent for the epidural.

Correct Answer: A

Rationale: The correct answer is A: administer oxygen. Fetal tachycardia indicates decreased oxygen supply to the fetus. Administering oxygen helps improve oxygenation to the fetus, addressing the root cause. Monitoring fetal heart rate (B) is important but not the priority over addressing the oxygen supply. Increasing fluid intake (C) does not directly address the fetal tachycardia. Increasing oxygen flow (D) is not necessary if the person is already receiving sufficient oxygen.

Correct Answer: A

Rationale: The correct answer is A: assess fetal heart rate. During the first stage of labor, monitoring fetal well-being is the priority to ensure the baby's safety. Assessing the fetal heart rate helps determine if the baby is tolerating labor well. Monitoring contractions (B) is important but assessing the fetal heart rate takes precedence. Administering oxytocin (C) should be done based on specific indications and not as a routine assessment during the first stage of labor. Checking for cervical dilation (D) is important but does not take priority over assessing fetal well-being.

Correct Answer: C

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