A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?

Insert an indwelling urinary catheter to maintain an empty blaadder at all times.

Keep four side rails up while the client is in bed, maintaining strict bedrest.

Monitor the fetal heart rate (FHR) hourly during active labor.

Check the cervix to determine how close the time of delivery may be prior to analgesic administration.

Answer and Explanation

The Correct Answer is D

Choice A: Insert an indwelling urinary catheter to maintain an empty bladder at all times.

Routinely inserting an indwelling urinary catheter is not necessary for maintaining an empty bladder during labor. While it is important to ensure the client has a voiding schedule, the use of an indwelling catheter should be reserved for specific medical indications, such as when the client is unable to void or has received an epidural. Indwelling catheters can increase the risk of catheter-associated urinary tract infections (CAUTIs) and should be used judiciously.

Choice B: Keep four side rails up while the client is in bed, maintaining strict bedrest.

Keeping all four side rails up and maintaining strict bedrest is not appropriate during active labor. This practice can limit the client’s movement, which is essential for comfort and progress during labor. Movement and changing positions can help labor progress and reduce pain. Strict bedrest is generally reserved for specific medical conditions, such as preterm labor or other complications.

Choice C: Monitor the fetal heart rate (FHR) hourly during active labor.

Monitoring the fetal heart rate (FHR) is crucial during labor to assess the well-being of the fetus. However, hourly monitoring may not be sufficient. Guidelines recommend more frequent monitoring, typically every 15-30 minutes during the active phase of labor and every 5-15 minutes during the second stage. Continuous electronic fetal monitoring may be used for high-risk pregnancies or if there are signs of fetal distress.

Choice D: Check the cervix to determine how close the time of delivery may be prior to analgesic administration.

Checking the cervix to determine how close the time of delivery may be prior to analgesic administration is important. This practice helps ensure that analgesics are administered at an appropriate time, avoiding potential complications such as delayed delivery or inadequate pain relief. Cervical checks provide valuable information about the progress of labor and help guide clinical decisions regarding pain management and delivery planning.

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Correct Answer is C

Explanation

A. 1 cm below the umbilicus: This is too low for a client at 22 weeks of gestation.

B. 3 cm below the umbilicus: This is also too low for a client at 22 weeks of gestation.

C. 2 cm above the umbilicus: At 22 weeks of gestation, the fundus should be palpated about 2 cm above the umbilicus, which is at approximately the level of the maternal belly button.
D. 3 cm above the umbilicus: This is too high for a client at 22 weeks of gestation.

A. Maintain the client in the lithotomy position. B. Encourage the client to empty her bladder every 2 hr. C. Remind the client to bear down with each contraction. D. Perform vaginal examinations frequently,

Correct Answer is B

Explanation

A. Maintain the client in the lithotomy position: The lithotomy position is not typically

maintained during the active phase of labor. It is used during the pushing stage (second stage) of labor.
B. Encourage the client to empty her bladder every 2 hr: A full bladder can impede fetal descent and progress during labor, so encouraging the client to empty her bladder regularly is essential.
C. Remind the client to bear down with each contraction: Bearing down during the active phase of labor is not appropriate, as it may lead to premature pushing and cervical swelling.
D. Perform vaginal examinations frequently: Frequent vaginal examinations can increase the risk of infection and should be minimized during labor.

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A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?

Choice A: Insert an indwelling urinary catheter to maintain an empty bladder at all times.

Choice B: Keep four side rails up while the client is in bed, maintaining strict bedrest.

Choice C: Monitor the fetal heart rate (FHR) hourly during active labor.

Choice D: Check the cervix to determine how close the time of delivery may be prior to analgesic administration.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to measure the fundal height of a client who is at 22 weeks of gestation. At which location should the nurse expect to palpate the fundus?

Correct Answer is C

Explanation

A nurse is caring for a client following an amniotomy who is now in the active phase of the first stage of labor. Which of the following actions should the nurse implement with this client?

Correct Answer is B

Explanation

A nurse is creating the plan of care for a client who is at 39 weeks of gestation and in active labor. Which of the following actions should the nurse include in the plan of care?

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