Page 755 - Saunders Comprehensive Review For NCLEX-RN

Health Problem: N/A
Priority Concepts: Clinical Judgment; Reproduction
Reference: McKinney et al. (2018), p. 300.

228. Answer: 3, 5

Rationale: Amniotomy (artificial rupture of the membranes) can be used to induce
labor when the condition of the cervix is favorable (ripe) or to augment labor if the
progress begins to slow. Rupturing of the membranes allows the fetal head to
contact the cervix more directly and may increase the efficiency of contractions.
Increased monitoring of maternal blood pressure is unnecessary after this procedure.
The fetal heart rate needs to be monitored frequently, as there is an increased
likelihood of a prolapsed cord with ruptured membranes and a high presenting part.
Test-Taking Strategy: Note the strategic words, most likely. Focus on the subject,
an amniotomy. Recalling that amniotomy is performed to augment labor if the
progress begins to slow will direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Maternity: Intrapartum
Health Problem: N/A
Priority Concepts: Client Education; Reproduction
Reference: Lowdermilk et al. (2016), p. 783.

229. Answer: 4

Rationale: Variable decelerations occur if the umbilical cord becomes compressed,
reducing blood flow between the placenta and the fetus. Variability refers to
fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and
usually occur with fetal movement. Early decelerations result from pressure on the
fetal head during a contraction.
Test-Taking Strategy: Focus on the subject, umbilical cord compression. Recalling
that variable decelerations occur if the umbilical cord becomes compressed will
direct you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Maternity: Intrapartum
Health Problem: Maternity: Fetal Distress/Demise
Priority Concepts: Clinical Judgment; Perfusion
Reference: McKinney et al. (2018), p. 343.

230. Answer: 1

Rationale: Vena cava and descending aorta compression by the pregnant uterus
impedes blood return from the lower trunk and extremities. This leads to decreasing
cardiac return, cardiac output, and blood flow to the uterus and subsequently the

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