When taking care of a client in labor who is not considered to be at risk, which assessments should be included in the plan of care? (Select all that apply.)
a. Check the DTR each shift.
b. Monitor and record vital signs frequently during the course of labor.
c. Document the FHR pattern, noting baseline and response to contraction patterns.
d. Indicate on the EFM tracing when maternal position changes are done.
e. Provide food, as tolerated, during the course of labor.
ANS: B, C, D
Nursing care of the normal laboring client would include monitoring and documentation of vital signs as part of the labor assessment, documentation the FHR, checking patterns to look for assurance of fetal well-being by evaluating baseline and the fetal response to contraction patterns, and noting any position changes on the monitor tracing to evaluate the fetal response. Providing dietary offerings during the course of labor is not part of the nursing care plan because the introduction of food may lead to nausea and vomiting in response to the labor process and might affect the mode of birth.
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