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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View Related questions
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 A
Explanation
Choice A rationale
Amniocentesis is a diagnostic test that involves extracting a small amount of amniotic fluid from the uterus to test for chromosomal abnormalities and genetic disorders. It is typically performed between 15 and 20 weeks of pregnancy. The fluid contains fetal cells and various chemicals produced by the baby, which can be analyzed to detect conditions such as Down syndrome, trisomy 18, and neural tube defects. This test is highly accurate and is often recommended when screening tests like the MSAFP indicate a potential issue.
Choice B rationale
A Nonstress Test (NST) is a non-invasive test that measures the fetal heart rate in response to its movements. It is used to assess fetal well-being, particularly in the third trimester, but it does not provide information about chromosomal abnormalities. The NST is typically used to monitor high-risk pregnancies and to ensure that the fetus is receiving enough oxygen.
Choice C rationale
A Biophysical Profile (BPP) combines an ultrasound with a Nonstress Test to evaluate the fetus’s health. It assesses fetal breathing movements, body movements, muscle tone, amniotic fluid volume, and heart rate reactivity. While it provides a comprehensive assessment of fetal well-being, it does not specifically diagnose chromosomal abnormalities. The BPP is often used in the third trimester to monitor high-risk pregnancies.
Choice D rationale
Chorionic Villus Sampling (CVS) is another diagnostic test that can detect chromosomal abnormalities and genetic disorders. It involves taking a small sample of placental tissue (chorionic villi) for analysis. CVS is typically performed between 10 and 13 weeks of pregnancy, earlier than amniocentesis. While it provides similar diagnostic information, it is not the test of choice following an abnormal MSAFP result, which is usually conducted later in pregnancy.