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 D

Explanation

A: Elevated temperature during labor may be common and is not the nurse's first priority, especially when the client is receiving epidural analgesia, as it can be related to the stress of labor or other factors.
B: Reduced sensation of the lower extremities is an expected effect of epidural analgesia, and it is not the nurse's first priority unless it leads to complications such as motor weakness or respiratory distress.
C: Generalized itching is a common side effect of epidural analgesia due to opioids, and it can be managed with interventions such as antihistamines. However, it is not the nurse's first priority unless it is severe or accompanied by other concerning symptoms.
D: Epidural analgesia can cause vasodilation and decrease the client's blood pressure, which can lead to hypotension. Hypotension can be detrimental to both the mother and the baby and requires immediate attention to prevent complications. Therefore, the nurse's first priority is to address the low blood pressure.

A. Turn the client onto her side. B. Increase the client's IV fluid infusion rate. C. Administer oxygen to the client. D. Palpate the client's uterus.

Correct Answer is A

Explanation

Choice A:The priority action when the fetal monitor tracing shows late decelerations after the client's membranes rupture is to turn the client onto her side. This position change helps relieve pressure on the vena cava and improves blood flow to the fetus.
Choice B: Increasing the client's IV fluid infusion rate is not the first priority in this situation, as late decelerations are primarily related to uteroplacental insufficiency rather than maternal hydration status.
Choice C: Administering oxygen to the client is important, but turning the client onto her side should be the first action to improve fetal oxygenation.
Choice D: Palpating the client's uterus is not the first priority in the presence of late

decelerations. The focus should be on relieving the compression on the vena cava and improving fetal oxygenation by changing the client's position.

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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 caring for a client who is receiving epidural analgesia during labor. Which of the following findings is the nurse's first priority?

Correct Answer is D

Explanation

A nurse is caring for a client who is in active labor when the client's membranes rupture. The fetal monitor tracing shows late decelerations. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation and who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?

A nurse is caring for a client who is 42 weeks of gestation. Based on the assessment findings, which of the following actions should the nurse plan to take? (Select all that apply.)

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?

A nurse is caring for a client who is in the first stage of labor, undergoing external fetal monitoring, and receiving IV fluid. The nurse observes variable decelerations in the fetal heart rate on the monitor strip. Which of the following is a correct interpretation of this finding?

A nurse is assessing a client who is in the third trimester of pregnancy. The nurse should recognize which of the following findings as an expected physiologic change during pregnancy?

A nurse in a prenatal clinic is instructing a client about an amniocentesis, which is scheduled at 15 weeks of gestation. Which of the following should be included in the teaching?

A nurse is caring for a client who is at 18 weeks of gestation. The client tells the nurse that she felt fluttering movements in her abdomen 3 days ago. The nurse should interpret this finding as which of the following?