During the fourth stage of labor, a nurse assesses the perineum of a birthing person who had a vaginal birth. What is the primary purpose of this assessment?

Correct Answer: C

Rationale: The primary purpose of assessing the perineum during the fourth stage of labor is to detect any signs of perineal trauma. This assessment is crucial to identify any tears or lacerations that may require immediate medical attention. By checking for perineal trauma, the nurse can ensure proper healing and prevent complications postpartum. Summary: A: Evaluating readiness for discharge is not the primary purpose of perineal assessment during the fourth stage of labor. B: Ensuring safe ambulation is important but not the primary reason for assessing the perineum. D: Assessing cervical dilation is not relevant during the fourth stage of labor where the focus shifts to monitoring postpartum recovery.

Correct Answer: A

Rationale: The correct answer is A: place the person in the knee-chest position. This is the priority nursing action because it helps relieve pressure on the cord and prevents further prolapse. Placing the person in the knee-chest position also promotes optimal fetal oxygenation. Administering oxygen via mask (choice B) is important but not the priority. Applying pressure to the cord (choice C) should never be done as it can further compromise blood flow to the fetus. Administering an epidural (choice D) is not the priority in this emergency situation.

Correct Answer: B

Rationale: The correct answer is B: encourage deep breathing exercises. Deep breathing helps prevent complications like pneumonia after surgery, aids in lung expansion, and promotes overall respiratory health. Choice A is important but not the most crucial post-cesarean. Choice C promotes mobility but doesn't address immediate respiratory needs. Choice D is important but not the most vital in the early postpartum period.

Correct Answer: B

Rationale: The primary benefit of delayed cord clamping in a term newborn is improved thermoregulation. When the cord is clamped later, it allows more blood to flow from the placenta to the baby, aiding in temperature stabilization. This helps prevent hypothermia, a common issue in newborns. Increased hemoglobin levels (choice A) are not the primary benefit of delayed cord clamping. Decreased risk of bleeding (choice C) is not directly related to delayed cord clamping. Increased risk of infection (choice D) is incorrect as delayed cord clamping does not increase the risk of infection.

Correct Answer: C

Rationale: The correct answer is C: perform gentle uterine massage. This intervention is appropriate as it helps to stimulate uterine contractions, which can reduce postpartum bleeding and pain. Uterine massage also helps to promote involution of the uterus, aiding in the recovery process. Administering IV fluids (A) may be necessary but does not directly address pain management. Administering narcotics (B) may provide pain relief but should be used judiciously due to potential side effects. Performing gentle fundal massage (D) is not recommended as it may cause discomfort and is not as effective in managing post-cesarean pain compared to uterine massage.