What is the priority intervention for a laboring person with a suspected uterine rupture?

Correct Answer: B

Rationale: The correct answer is B: perform uterine massage. This intervention aims to prevent excessive bleeding and stabilize the uterus. Uterine massage helps to maintain uterine tone, which is crucial in managing uterine rupture. This intervention can help reduce the risk of maternal hemorrhage and improve fetal oxygenation. Incorrect choices: A: Emergency cesarean section may be necessary but is not the priority as immediate measures to control bleeding and maintain uterine tone are crucial. C: Applying pressure to the abdomen is not recommended as it can further exacerbate uterine rupture and increase the risk of complications. D: Continuous monitoring of the fetal heart rate is important but not the priority in managing uterine rupture, which requires immediate intervention to prevent maternal and fetal complications.

Correct Answer: C

Rationale: The correct answer is C: assess uterine tone. This is the priority assessment during oxytocin infusion because oxytocin can cause uterine hyperstimulation, leading to fetal distress. By assessing uterine tone regularly, the nurse can detect any signs of hyperstimulation early and take appropriate action to prevent complications. Monitoring fetal heart rate (A) is important but assessing uterine tone takes precedence as it directly impacts fetal well-being. Maternal vital signs (B) are important but are not as directly related to the safety of the fetus during oxytocin infusion. Monitoring for signs of uterine hyperstimulation (D) is essential, but assessing uterine tone is the proactive approach to detect hyperstimulation before it escalates.

Correct Answer: B

Rationale: The correct initial action is to monitor blood pressure (B) because postpartum headache could indicate preeclampsia, a serious condition characterized by high blood pressure. Monitoring blood pressure is crucial to assess for signs of preeclampsia. Administering pain medication (A) may mask symptoms, performing a neurological assessment (C) may not address the underlying cause, and providing oxygen (D) is not the priority without knowing the cause of the headache.

Correct Answer: A

Rationale: The correct answer is A: Swelling and redness of the calf. Postpartum women are at a higher risk for DVT due to hormonal changes and immobility. Swelling and redness in the calf indicate possible DVT as blood clots can cause inflammation and blockage in the veins. Pain in the lower leg (B) is a common symptom but not the most specific for DVT. Heat intolerance (C) and cold intolerance (D) are not typically associated with DVT and are unrelated symptoms in this context.

Correct Answer: D

Rationale: The correct answer is D: to control excessive vaginal bleeding. Episiotomy is primarily performed to manage and control postpartum hemorrhage by facilitating better visualization and access for suturing any bleeding vessels. It is not routinely done for preventing severe tears, expediting birth, or addressing shoulder dystocia, as there are alternative interventions for these situations. Episiotomy should be carefully considered and performed only when necessary to avoid unnecessary complications and promote better outcomes.