Page 756 - Saunders Comprehensive Review For NCLEX-RN

fetus. The best position to prevent this would be side-lying, with the uterus
displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a
supine position, however; a wedge placed under the right hip provides displacement
of the uterus. Trendelenburg’s position places pressure from the pregnant uterus on
the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A prone
or semi-Fowler’s position is not practical for this type of abdominal surgery.
Test-Taking Strategy: Focus on the subject, positioning the pregnant woman.
Visualizing each of the positions identified in the options and considering the effect
that the position may have on the mother and the fetus 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: Maternity: Supine Hypotension
Priority Concepts: Clinical Judgment; Perfusion
Reference: McKinney et al. (2018), pp. 390-391.

231. Answer: 1

Rationale: A normal fetal heart rate is 110 to 160 beats per minute, and the fetal
heart rate should be within this range between contractions. Fetal bradycardia
between contractions may indicate the need for immediate medical management,
and the PHCP or nurse-midwife needs to be notified. Options 2, 3, and 4 are
inappropriate nursing actions in this situation and delay necessary intervention.
Test-Taking Strategy: Note the strategic words, most appropriate. Focus on the data
in the question. Knowledge that the normal fetal heart rate is 110 to 160 beats per
minute will assist you to recognize that fetal bradycardia is present.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Maternity: Intrapartum
Health Problem: Maternity: Fetal Distress/Demise
Priority Concepts: Clinical Judgment; Perfusion
Reference: Lowdermilk et al. (2016), pp. 419-420.

232. Answer: 4

Rationale: Accelerations are transient increases in the fetal heart rate that often
accompany contractions or are caused by fetal movement. Episodic accelerations are
thought to be a sign of fetal well-being and adequate oxygen reserve. Options 1, 2,
and 3 are inaccurate nursing actions and are unnecessary.
Test-Taking Strategy: Note the strategic words, most appropriate. Options 1, 2, and
3 are comparable or alike in that they indicate the need for further intervention.
Also, knowing that accelerations indicate fetal well-being will direct you to the
correct option.
Level of Cognitive Ability: Analyzing

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