Page 757 - Saunders Comprehensive Review For NCLEX-RN

Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Maternity: Intrapartum
Health Problem: N/A
Priority Concepts: Clinical Judgment; Perfusion
Reference: Lowdermilk et al. (2016), p. 420.

233. Answer: 2

Rationale: Assessing the baseline fetal heart rate is important so that abnormal
variations of the baseline rate can be identified if they occur. The intensity of
contractions is assessed by an internal fetal monitor, not an external fetal monitor.
Options 1 and 4 are important to assess, but not as the first priority. Fetal heart rate
is evaluated by assessing baseline and periodic changes. Periodic changes occur in
response to the intermittent stress of uterine contractions and the baseline beat-to-
beat variability of the fetal heart rate.
Test-Taking Strategy: Note the strategic word, next. Use the ABCs—airway,
breathing, and circulation. Fetal heart rate reflects the ABCs.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Maternity: Intrapartum
Health Problem: N/A
Priority Concepts: Clinical Judgment; Perfusion
Reference: McKinney et al. (2018), pp. 338-339.

234. Answer: 4

Rationale: True labor is present when contractions increase in duration and
intensity. Lightening or dropping leads to engagement (presenting part reaches the
level of the ischial spine) and occurs when the fetus descends into the pelvis about 2
weeks before delivery. Contractions felt in the abdominal area and contractions that
ease with walking are signs of false labor.
Test-Taking Strategy: Focus on the subject, the signs of true labor. Noting the
word true in the question and its relationship to the words increase in duration and
intensity in the correct option will direct you to this option.
Level of Cognitive Ability: Evaluating
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching and Learning
Content Area: Maternity: Intrapartum
Health Problem: N/A
Priority Concepts: Clinical Judgment; Reproduction
Reference: McKinney et al. (2018), pp. 298-299

235. Answer: 3

Rationale: Fetal heart rate is assessed immediately after amniotomy to detect any

757