A pregnant person in the first stage of labor experiences rupture of membranes. What is the nurse's priority action?

Correct Answer: C

Rationale: The correct answer is C because documenting the fetal heart rate (FHR) and characteristics of amniotic fluid is crucial to assess fetal well-being and monitor for signs of distress. This information helps guide further management decisions. Administering an epidural (A) is not the priority at this stage. Starting an IV line and administering antibiotics (B) may be needed later but not the immediate priority. Preparing for immediate delivery (D) is premature without assessing the fetal status first.

Correct Answer: A

Rationale: The correct answer is A: observe for respiratory effort. This is the first step because it helps the nurse quickly assess if the newborn is breathing effectively. Observing for respiratory effort allows for prompt identification of any potential respiratory distress or abnormalities. Taking the newborn's temperature (B) is important but not the first step in assessing respiratory status. Assisting with suctioning the airways (C) should only be done if there are signs of airway obstruction, not as the initial step. Suctioning the newborn's mouth (D) is not recommended immediately after birth unless there is clear obstruction, as this can stimulate unnecessary reflexes and cause harm.

Correct Answer: C

Rationale: The correct answer is C: to reduce the risk of seizures and cerebral hemorrhage. Magnesium sulfate is used during preterm labor to prevent and treat seizures in women with preeclampsia and eclampsia. It acts as a neuroprotective agent by preventing cerebral vasoconstriction and reducing the risk of cerebral hemorrhage. The other choices are incorrect because magnesium sulfate does not primarily relax the uterus to prevent contractions (A), improve fetal oxygenation (B), or decrease blood pressure (D) during preterm labor.

Correct Answer: A

Rationale: The correct answer is A: administer a test dose of anesthesia. Before administering an epidural, it is crucial to perform a test dose to assess the person's response and ensure correct placement of the catheter. This step helps prevent potential complications such as unintentional intravascular injection. Summary: B: Ensuring informed consent is important but not the priority before administering the test dose. C: Administering IV fluids is important for hydration but not the immediate priority before the test dose. D: Continuous fetal monitoring is essential during labor, but it is not the priority before administering the test dose of anesthesia.

Correct Answer: A

Rationale: The correct answer is A: Progressive cervical dilation. This is the most reliable indicator of the active phase of labor because it directly reflects the opening of the cervix, indicating that labor is advancing. Cervical dilation is a key aspect of labor progress and is used to determine the stage of labor. Frequent, regular contractions (choice B) are important but can occur in early labor as well. Fetal descent (choice C) is an important aspect but may happen in conjunction with cervical dilation. Effacement of the cervix (choice D) is also important but does not solely indicate the active phase of labor.