What is the first step the nurse should take when assessing a newborn's respiratory status immediately after birth?

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: 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.

Correct Answer: C

Rationale: The correct answer is C, bradycardia. Bradycardia in the fetal heart rate is a significant finding indicating fetal distress because it signifies a heart rate below normal range, which can lead to inadequate oxygen supply to the fetus. Bradycardia can be a sign of fetal hypoxia, acidosis, or other serious conditions. Variable decelerations (choice A) are often caused by umbilical cord compression, late decelerations (choice B) are associated with uteroplacental insufficiency, and accelerations (choice D) are considered a reassuring sign of fetal well-being. Therefore, in the context of fetal distress, bradycardia is the most concerning finding.

Correct Answer: C

Rationale: The correct answer is C: apply oxygen via mask. This is the primary nursing action for a ruptured uterus because it helps improve oxygenation to the laboring person and the fetus. Ruptured uterus can lead to a significant decrease in oxygen supply, so providing oxygen is crucial. Incorrect choices: A: preparing for an emergency cesarean section is important but not the primary action in this situation. B: providing pain relief is important, but ensuring oxygenation is a higher priority. D: applying pressure to the abdomen is not recommended as it can worsen the condition.