A nurse is creating the plan of care for a client in active labor. Which of the following actions should the nurse include in the plan of care?
Keep four side rails up.
Insert an indwelling urinary catheter.
Check the cervix prior to administering medication.
Monitor the fetal heart rate (FHR) every hour.
The Correct Answer is C
Choice A rationale
Keeping four side rails up is a safety measure to prevent falls, but it is not specific to the care of a client in active labor. It is a general safety precaution used for clients who are at risk of falling or have impaired mobility.
Choice B rationale
Inserting an indwelling urinary catheter is not a routine action for a client in active labor. Catheterization is typically reserved for specific medical indications, such as urinary retention or the need for accurate urine output measurement in certain high-risk situations.
Choice C rationale
Checking the cervix prior to administering medication is crucial in active labor. This ensures that the medication is appropriate for the stage of labor and helps avoid complications such as administering pain relief too early or too late, which could affect labor progression and fetal well-being.
Choice D rationale
Monitoring the fetal heart rate (FHR) every hour is important, but it may not be frequent enough in active labor. Continuous or more frequent monitoring is often required to promptly detect any signs of fetal distress and take appropriate actions.
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Correct Answer is A
Explanation
Choice A rationale
The “Passenger” refers to the fetus and its position, size, and presentation. In this case, the fetus has an estimated weight of 9 lbs and is in the left occiput posterior (LOP) position. These factors can complicate labor by making it more difficult for the fetus to navigate through the birth canal, potentially leading to prolonged labor and increased risk of interventions.
Choice B rationale
The “Passage” refers to the birth canal, including the pelvis and soft tissues. While the passage is an important factor in labor, the primary concern in this scenario is the size and position of the fetus, which falls under the “Passenger” category.
Choice C rationale
The “Powers” refer to the strength and frequency of uterine contractions. Although the patient is having contractions every 3 minutes, the main concern here is the fetal size and position, which are more directly related to the "Passenger"4.
Choice D rationale
The “Psyche” refers to the psychological state of the mother, including her stress levels and emotional well-being. While important, the primary concern in this scenario is the physical factors related to the fetus, which are categorized under the "Passenger"4.
Correct Answer is B
Explanation
Choice A rationale
Monitoring the patient’s vocalizations and facial expressions can provide some information about the intensity of contractions, but it is subjective and not a reliable method for accurately assessing contraction intensity.
Choice B rationale
Palpating the maternal abdomen during a contraction is the best method for determining the intensity of contractions. By feeling the firmness of the uterus, the nurse can assess whether the contractions are mild, moderate, or strong. This method provides a more objective measure of contraction intensity compared to other methods.
Choice C rationale
Timing the amount of time between the ending of one contraction and the beginning of the next provides information about the frequency of contractions, not their intensity. This choice does not address the question of how to determine contraction intensity.
Choice D rationale
Palpating the maternal abdomen right after a contraction does not provide information about the intensity of the contraction that just occurred. The uterus will be relaxed after the contraction, making it difficult to assess the strength of the previous contraction.