Page 753 - Saunders Comprehensive Review For NCLEX-RN

the past hour. What is the priority nursing action?
1. Notify the health care provider.
2. Discontinue the infusion of oxytocin.
3. Place oxygen on at 8 to 10 L/minute via face mask.
4. Contact the client’s primary support person(s) if not currently
present.

Answers

224. Answer: 3, 5

Rationale: The second stage of labor begins when the cervix is dilated completely
and ends with birth of the neonate. The woman has a strong urge to push in stage 2
when the Ferguson reflex is activated. Options 1, 2, and 4 are not specific assessment
findings of the second stage of labor and occur in stage 1.
Test-Taking Strategy: Eliminate options 2 and 4 first because they are comparable
or alike. From the remaining options, recalling that regular contractions occur before
the second stage of labor will direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process—Assessment
Content Area: Maternity: Intrapartum
Health Problem: N/A
Priority Concepts: Clinical Judgment; Reproduction
Reference: McKinney et al. (2018), p. 299.

225. Answer: 1

Rationale: Late decelerations are due to uteroplacental insufficiency and occur
because of decreased blood flow and oxygen to the fetus during the uterine
contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is
necessary. The supine position is avoided because it decreases uterine blood flow to
the fetus. The client should be turned onto her side to displace pressure of the gravid
uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued
when a late deceleration is noted. The oxytocin would cause further hypoxemia
because of increased uteroplacental insufficiency resulting from stimulation of
contractions by this medication. Although the nurse would document the
occurrence, option 4 would delay necessary treatment.
Test-Taking Strategy: Note the strategic words, most appropriate. Use the ABCs—
airway, breathing, and circulation—and knowledge related to the significance of a
late deceleration to answer this question.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Maternity: Intrapartum
Health Problem: Maternity: Fetal Distress/Demise

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