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 A

Explanation

A. Position the client on her side: Late decelerations are often associated with uteroplacental insufficiency, which may be improved by changing the maternal position to improve blood flow to the placenta.
B. Elevate the client's legs: Elevating the client's legs would not directly address the cause of late decelerations.
C. Increase the infusion rate of the IV fluid: While ensuring adequate hydration is important, it is not the priority action when late decelerations are noted.
D. Administer oxygen via a face mask: Oxygen administration may be necessary, but it is not the priority action. Positioning the client on her side to improve blood flow is the priority.

A. "Assist the client in slowing her hyperventilation and breathe into a paper bag." B. "Administer oxygen via nasal cannula while encouraging her to pant." C. "Have the client tuck her chin to her chest." D. "Instruct the client to increase her respiratory rate to more than 42 breaths per minute."

Correct Answer is A

Explanation

Choice A: The client's symptoms of lightheadedness and tingling fingers indicate that she may be hyperventilating, which can occur when patternpaced breathing is too rapid. Breathing into a paper bag can help the client rebreathe some of the exhaled carbon dioxide, which can help correct the respiratory alkalosis caused by hyperventilation.

Choice B: Administering oxygen via nasal cannula may not address the underlying issue of hyperventilation. It is more appropriate to assist the client in slowing down her breathing pattern.

Choice C: Tucking the chin to the chest is not relevant to the client's symptoms of hyperventilation.

Choice D: Instructing the client to increase her respiratory rate would exacerbate the hyperventilation, leading to more symptoms of respiratory alkalosis.

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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 in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

Correct Answer is A

Explanation

A nurse is caring for a client who is in the first stage of labor and is using patternpaced breathing. The client says she feels lightheaded, and her fingers are tingling. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

A nurse admits a woman who is at 38 weeks of gestation and in early labor with ruptured membranes. The nurse determines that the client's oral temperature is 38.9°C (102°F). Besides notifying the provider, which of the following is an appropriate nursing action?

A nurse on the labor and delivery unit is caring for a client who is having a difficult, prolonged labor with severe backache. Which of the following contributing causes should the nurse identify?

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?

A nurse is providing dietary education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification?

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?

A nurse is caring for a client at the first prenatal visit who has a BMI of 26.5. The client asks how much weight she should gain during pregnancy. Which of the following responses should the nurse make?