A nurse is preparing to administer a medication to a birthing person with a history of hypertension. What is the nurse's priority assessment before administering this medication?

Correct Answer: A

Rationale: The correct answer is A: Blood pressure and pulse rate. For a birthing person with a history of hypertension, it is crucial to assess their blood pressure and pulse rate before administering medication to ensure the medication does not exacerbate their hypertension. Monitoring these vital signs helps in determining the appropriateness and safety of the medication. Summary: - Choice B is incorrect because respiratory rate and oxygen saturation are not the priority assessments for a person with a history of hypertension. - Choice C is incorrect as temperature and urine output are not directly related to assessing the risk of exacerbating hypertension. - Choice D is incorrect as oxygen saturation and urine output are not the primary indicators of medication safety for someone with hypertension.

Correct Answer: C

Rationale: The correct answer is C: to assess fetal heart rate accelerations. An NST is used to monitor the baby's heart rate and movement to ensure adequate oxygen supply. Fetal heart rate accelerations indicate a healthy, responsive baby. Assessing heart rate variability (A) is important but not the primary purpose. Evaluating fetal well-being (B) is broad and doesn't capture the specific focus on heart rate accelerations. Assessing maternal well-being (D) is not the purpose of an NST.

Correct Answer: A

Rationale: The correct answer is A: apply gentle pressure to the fetal head. This action helps prevent rapid delivery, reducing the risk of perineal tearing and promoting controlled delivery of the baby. Applying pressure also helps prevent the baby from being born too quickly, reducing the risk of umbilical cord compression and potential birth injuries. Choices B, C, and D are incorrect because at the moment the head crowns, the priority is to assist with the controlled delivery of the baby's head. Delivering the placenta (B) and assisting with shoulder delivery (C) are steps that come after the baby's head is delivered. Applying pressure to the perineum (D) is not recommended as it may increase the risk of perineal tearing.

Correct Answer: A

Rationale: The primary purpose of performing an episiotomy during delivery is to reduce the risk of perineal trauma. Episiotomy is a surgical incision made in the perineum to widen the vaginal opening during childbirth, which can help prevent severe tearing of the perineal tissue. This procedure is performed to provide controlled and precise incision, reducing the likelihood of extensive tears that may lead to complications such as infection or prolonged healing time. It is not done to promote faster delivery, facilitate fetal descent, or provide immediate fetal oxygenation. These choices do not accurately reflect the main goal of episiotomy, which is to minimize perineal trauma.

Correct Answer: A

Rationale: The correct answer is A: perform uterine massage. This is the priority because uterine massage helps to stimulate uterine contractions, which can help control bleeding in postpartum individuals. It is crucial to address the source of bleeding first. Performing a vaginal examination (choice B) may exacerbate bleeding. Evaluating blood loss (choice C) is important but not the initial step. Performing a uterine check (choice D) is vague and not as specific as uterine massage in addressing postpartum bleeding.