A postpartum person is experiencing a headache after delivery. What is the most appropriate initial nursing action?

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.

Correct Answer: D

Rationale: The correct answer is D: to control excessive vaginal bleeding. Episiotomy is primarily performed to manage and control postpartum hemorrhage by facilitating better visualization and access for suturing any bleeding vessels. It is not routinely done for preventing severe tears, expediting birth, or addressing shoulder dystocia, as there are alternative interventions for these situations. Episiotomy should be carefully considered and performed only when necessary to avoid unnecessary complications and promote better outcomes.

Correct Answer: C

Rationale: Rationale: C is correct because assessing for uterine atony is crucial before administering a postpartum tetanus shot to ensure no postpartum hemorrhage risk. Uterine atony can lead to excessive bleeding, which can be exacerbated by the tetanus shot. Summary: A - Verifying immunization status is important but not the most immediate action. B - Assessing blood pressure is important but not directly related to the risk of postpartum hemorrhage. D - Preparing for a cesarean section is not necessary for administering a postpartum tetanus shot.

Correct Answer: A

Rationale: The correct answer is A: perform uterine massage. This is the priority intervention for a boggy uterus to prevent postpartum hemorrhage by promoting uterine contraction and reducing bleeding. Uterine massage helps the uterus to firm up and expel clots. Early ambulation (B) and positioning (C) can support recovery but do not directly address the boggy uterus. Performing a pelvic exam (D) is not necessary for managing a boggy uterus and may even exacerbate bleeding.

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.