A nurse is preparing to administer a tetanus toxoid vaccine to a postpartum person. What is the nurse's priority action before administering the vaccine?

Correct Answer: D

Rationale: The correct answer is D: ensure proper positioning for the vaccine. It is essential to ensure the person is in the correct position before administering the vaccine to ensure accurate and safe administration. Proper positioning helps prevent injury and ensures the vaccine is administered correctly. Verifying the person's immunization history (choice A) is important but not the priority before administering the vaccine. Informed consent (choice B) should be obtained but is not the priority action in this scenario. Checking for signs of an allergic reaction (choice C) is important but should be done after ensuring proper positioning for the vaccine.

Correct Answer: B

Rationale: The correct answer is B: feeling hopeless. Postpartum depression is a serious condition that can lead to feelings of hopelessness, helplessness, and worthlessness. This is concerning as it may indicate a deeper level of despair and potential suicidal ideation. Feeling overwhelmed (choice A) is common in new parents but not necessarily indicative of postpartum depression. Low energy and fatigue (choice C) can be symptoms of depression but are not the most concerning sign. Feeling elated (choice D) is not characteristic of postpartum depression but may indicate other mood disorders.

Correct Answer: B

Rationale: The correct answer is B: apply cold compresses. Cold compresses help reduce inflammation and numb the area, providing pain relief for sore nipples. Warm compresses can worsen pain by increasing blood flow. Distraction techniques do not address the root cause of nipple pain. Lanolin cream is commonly used for nipple pain, but it may not provide immediate relief like cold compresses. Cold compresses are the most appropriate intervention in this situation.

Correct Answer: B

Rationale: The correct answer is B: administer pain relief. Nipple pain during breastfeeding can be caused by various factors such as improper latch, engorgement, or infection. Administering pain relief can help alleviate the discomfort temporarily while addressing the root cause. Applying lanolin cream (choice A) may help with moisturizing the nipples but won't address the underlying issue causing the pain. Monitoring the baby's latch (choice C) is important for long-term prevention but may not provide immediate relief. Providing distraction techniques (choice D) is not addressing the physical pain and may not be effective in resolving the issue. Administering pain relief is the most appropriate immediate action to help the postpartum person manage the discomfort while addressing the cause of the pain.

Correct Answer: C

Rationale: The correct answer is C: pale skin. This is because the most common early sign of postpartum hemorrhage is hypovolemia, which leads to decreased perfusion and oxygenation of tissues. Pale skin indicates decreased blood flow and oxygen delivery, a key indicator of hypovolemia. Excessive bleeding (choice A) is a symptom, not a sign. Low blood pressure (choice B) is a late sign of postpartum hemorrhage. Dark red bleeding (choice D) may indicate the presence of clots but is not specific to early postpartum hemorrhage.