Author Question: The nurse is caring for a low-risk client in the active phase of labor. At which interval should the ... (Read 49 times)

brutforce · **on:** Jun 28, 2018

The nurse is caring for a low-risk client in the active phase of labor. At which interval should the nurse assess the fetal heart rate?

a. Every 15 minutes
b. Every 30 minutes
c. Every 45 minutes
d. Every 1 hour

Question 2

A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity.

Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the client to be:

a. discharged home with a sedative.
b. admitted for extended observation.
c. admitted and prepared for a cesarean birth.
d. discharged home to await the onset of true labor.

makaylafy · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: B
For the fetus at low risk for complications, guidelines for frequency of assessments are at least every 30 minutes during the active phase of labor. 15-minute assessments would be appropriate for a fetus at high risk. 45-minute assessments during the active phase of labor are not frequent enough to monitor for complications. 1-hour assessments during the active phase of labor are not frequent enough to monitor for complications.

Answer to Question 2

ANS: D
The situation describes a client with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. The client will probably be discharged, but there is no indication that a sedative is needed. These are all indications of false labor; there is no indication that further assessment or observations are indicated. These are all indications of false labor without fetal distress. There is no indication that a cesarean birth is indicated.