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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) "Maybe next time you can have a vaginal delivery.": This response may not be appropriate as it assumes a future pregnancy and vaginal delivery is guaranteed. It may not address the client's current feelings of disappointment adequately.
B) "It sounds like you are feeling sad that things didn't go as planned.": This is the correct answer as it shows empathy and validates the client's feelings of disappointment. It acknowledges the client's emotions and provides support during this sensitive time.
C) "You can resume sexual relations sooner than if you had delivered vaginally.": While this statement may be true, it is not directly related to the client's expressed feelings of disappointment.
D) "At least you know you have a healthy baby.": This response dismisses the client's feelings and may not be wellreceived, as the client is expressing a desire for emotional support rather
than a reassurance about the baby's health.
Correct Answer is ["B","E"]
Explanation
Choice A: Amniocentesis is not primarily performed to determine the gender of the fetus. The main indication for this procedure is to detect genetic abnormalities or chromosomal disorders.
Choice B: The primary purpose of an amniocentesis is to detect chromosomal abnormalities such as Down syndrome (trisomy 21), trisomy 18, and trisomy 13, among others.
Choice C: Rh incompatibility is assessed through blood tests, not amniocentesis. It involves determining the Rh factor of the mother's blood and monitoring for potential Rh sensitization.
Choice D: Cephalopelvic disproportion refers to a situation where the baby's head is too large or the mother's pelvis is too small to allow for a vaginal delivery. It is not related to amniocentesis.
Choice E: While detecting neural tube defects can be done through amniocentesis, it is not the primary indication for the procedure. Neural tube defects can also be screened for through blood tests and ultrasound examinations. Amniocentesis is more commonly used for chromosomal analysis.
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