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?

A. Keep four side rails up while the client is in bed: Using all four side rails continuously is considered a restraint and is not necessary unless the client is sedated or disoriented. Standard safety precautions include raising only two or three side rails and monitoring for changes in condition. B. Check the cervix prior to analgesic administration: Assessing cervical dilation before giving analgesics is essential to ensure the client is not in the late stages of labor. Administering certain analgesics too close to delivery can depress neonatal respiratory effort, so verifying labor progress helps ensure safe and timely pain management. C. Monitor the fetal heart rate (FHR) every hour: During active labor, fetal heart rate monitoring should occur at least every 15 to 30 minutes for low-risk clients and more frequently for high-risk clients. Monitoring only once an hour is insufficient. D. Insert an indwelling urinary catheter: Routine placement of an indwelling catheter is not recommended in active labor unless medically indicated. Intermittent catheterization or encouraging voiding is preferred to reduce infection risk and promote mobility during labor.