Page 634 - Saunders Comprehensive Review For NCLEX-RN

Reference: Lowdermilk et al. (2016), p. 278.

187. Answer: 3

Rationale: The FHR depends on gestational age and ranges from 160 to 170 beats
per minute in the first trimester but slows with fetal growth to 110 to 160 beats per
minute. If the FHR is less than 110 beats per minute or more than 160 beats per
minute with the uterus at rest, the fetus may be in distress. Because the FHR is
increased from the reference range, the nurse should notify the OB. Options 2 and 4
are inappropriate actions based on the information in the question. Although the
nurse documents the findings, based on the information in the question, the OB
needs to be notified.
Test-Taking Strategy: Focus on the data in the question and note the strategic
word, priority. Then, note if an abnormality exists. Also note the FHR and that the
client is at 38 weeks of gestation. Remember that the normal FHR is 110 to 160 beats
per minute.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Maternity: Antepartum
Health Problem: Maternity: Fetal Distress/Demise
Priority Concepts: Clinical Judgment; Perfusion
Reference: McKinney et al. (2018), p. 339.

188. Answer: 3

Rationale: The tubal isthmus remains contracted until 3 days after conception to
allow the fertilized ovum to develop within the tube. This initial growth of the
fertilized ovum promotes its normal implantation in the fundal portion of the
uterine corpus. Estrogen is a hormone produced by the ovarian follicles, corpus
luteum, adrenal cortex, and placenta during pregnancy. Progesterone is a hormone
secreted by the corpus luteum of the ovary, adrenal glands, and placenta during
pregnancy. Luteinizing hormone and follicle-stimulating hormone are excreted by
the anterior pituitary gland. The survival of the fertilized ovum does not depend on
it staying in the fallopian tube for 3 days.
Test-Taking Strategy: Note the strategic word, best, and use knowledge of the
anatomy and physiology of the female reproductive system. Remember that
fertilization occurs in the fallopian tube and the fertilized ovum remains in the
fallopian tube for about 3 days. This promotes its normal implantation.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Maternity: Antepartum
Health Problem: N/A
Priority Concepts: Development; Reproduction
Reference: McKinney et al. (2018), p. 198.

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