How often should the nurse assess the blood pressure, pulse, and respirations of the birthing person during the first hour of the fourth stage of labor?

Correct Answer: A

Rationale: The correct answer is A: every 15 minutes. During the first hour of the fourth stage of labor, immediate postpartum assessment is crucial to monitor for any signs of complications such as hemorrhage or shock. Assessing vital signs every 15 minutes allows for early detection of any abnormalities and prompt intervention. This frequency ensures close monitoring of the birthing person's condition and helps in early identification of any potential issues. Choices B, C, and D are incorrect because less frequent assessments may delay the identification of complications, potentially leading to serious consequences. Option C, in particular, is dangerous as it suggests delaying assessments when immediate postpartum monitoring is essential.

Correct Answer: A

Rationale: The correct answer is A: uterine overdistention. Uterine atony is when the uterus fails to contract effectively after childbirth. Overdistention, such as from multiple gestation or large baby, can stretch the uterus, leading to poor muscle tone. This results in inadequate contractions to control bleeding. Excessive uterine contractions (B) are not a common cause but rather can lead to other issues like uterine rupture. Placental abruption (C) is the premature separation of the placenta from the uterus, causing bleeding but not directly related to atony. Infection or retained placenta (D) can contribute to uterine atony but are not common primary causes.

Correct Answer: C

Rationale: The most appropriate intervention for pain management in a postpartum person with a second-degree perineal tear is administering non-pharmacological pain relief (Choice C). This includes methods such as sitz baths, warm compresses, and positioning techniques. These interventions are effective in reducing pain and promoting healing without the side effects associated with medications or invasive procedures. Oral pain medication (Choice A) may not be sufficient for managing the specific pain in this case. Administering an epidural analgesic (Choice B) is not appropriate postpartum, as it is typically used during labor for pain relief. Ice packs (Choice D) may provide temporary relief but do not address the underlying pain and healing process as effectively as non-pharmacological methods.

Correct Answer: B

Rationale: The correct answer is B: administer epidural analgesia. In the first stage of labor, epidural analgesia is the most appropriate option for pain relief as it provides effective and continuous pain management without compromising maternal and fetal well-being. Epidural analgesia allows the laboring person to remain alert and actively participate in the birthing process. Non-pharmacological pain relief methods may not provide sufficient pain relief during the intense contractions of the first stage of labor. Administering IV analgesics may not effectively manage the pain in the first stage and can have sedative effects on the laboring person and newborn. Administering pain medication as requested without considering the most appropriate option may not provide optimal pain relief and may not be in the best interest of the laboring person and their baby.

Correct Answer: A

Rationale: The correct answer is A: keep the cord dry and clean. This is because keeping the umbilical cord dry and clean helps prevent infection and promotes healing. Applying a sterile dressing (B) is unnecessary and may trap moisture, leading to infection. Using alcohol or iodine (C) is outdated and can delay cord separation. Applying a sterile dressing to the umbilicus (D) is not recommended as it can interfere with air circulation and healing. In summary, choice A is correct as it aligns with current best practices for umbilical cord care.