The nurse notes that a patient who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take?

Correct Answer: C

Rationale: The correct answer is C: Document this evidence of normal early maternal-infant attachment behavior. This is the correct action because the mother's behavior of touching her infant with her fingertips and talking to him softly in high-pitched tones is indicative of normal maternal-infant attachment. This behavior shows that the mother is engaging with her infant in a positive and nurturing way, which is crucial for bonding and attachment. It is important for the nurse to document this behavior as it reflects a healthy interaction between the mother and her newborn. Other choices are incorrect: A: Request a social service consult for psychosocial support - This choice is not necessary as the mother's behavior indicates normal attachment and does not suggest a need for psychosocial support at this time. B: Observe for other signs that the mother may not be accepting of the infant - This choice is unnecessary as the mother's current behavior demonstrates acceptance and attachment towards her infant. D: Determine whether the mother is too fatigued to interact normally

Correct Answer: C

Rationale: The correct answer is C. Including test results ensuring that the fluid is not urine in the patient's record is crucial after a spontaneous rupture of membranes to confirm the presence of amniotic fluid, indicating the onset of labor. This information helps in assessing the progress of labor and ensuring the safety of both the mother and the fetus. A: Fetal heart rate is important but not directly related to the spontaneous rupture of membranes. It should be monitored separately. B: Pain level is subjective and can vary among individuals, not directly related to the rupture of membranes. D: The patient's understanding of the event is important for communication but does not provide essential clinical information related to the rupture of membranes.

Correct Answer: A

Rationale: After the baby's head is born, the immediate next step is the expulsion of the baby's body. This is because the expulsion maneuver refers to the delivery of the rest of the baby's body following the birth of the head. Restitution, internal rotation, and external rotation occur before the birth of the baby's head and are part of the cardinal movements of labor and birth. Restitution involves the realignment of the baby's head with their body after the head is born. Internal rotation refers to the baby's head turning to navigate through the birth canal. External rotation involves the baby's head turning back to its original position after delivery. So, the correct answer is A (Expulsion), as it directly follows the birth of the baby's head.

Correct Answer: D

Rationale: Rationale: 1. Past 42 weeks of gestation increases the risk of stillbirth. 2. Oxytocin can help initiate labor to reduce the risk. 3. Induction at this stage is considered safe and beneficial. 4. Other choices are not direct indications for oxytocin induction and may have different management strategies. Summary: - A: Multiple fetuses and polyhydramnios may require different approaches. - B: History of long labors may not necessarily indicate the need for oxytocin induction.

Correct Answer: A

Rationale: The correct answer is A because a patient in transition with contractions every 2 minutes lasting 90 seconds each is experiencing very intense and frequent contractions, indicating high uterine activity. Discontinuing oxytocin infusion is crucial in this scenario to prevent hyperstimulation, which can lead to fetal distress or uterine rupture. Choice B is incorrect because the patient is in early labor and the contractions are less frequent and less intense compared to the correct answer. Choice C is incorrect as the patient in active labor with contractions every 3 minutes lasting 60 seconds each is not as intense as the patient in transition in the correct answer. Choice D is incorrect because although the contractions are frequent and lasting longer, the intensity described in choice A is more concerning and requires immediate discontinuation of oxytocin infusion.