Page 758 - Saunders Comprehensive Review For NCLEX-RN

changes that may indicate cord compression or prolapse. When the membranes are
ruptured, minimal vaginal examinations would be done because of the risk of
infection. Bladder distention or maternal blood pressure would not be the first thing
to check after an amniotomy.
Test-Taking Strategy: Note the strategic word, first. Because of the risk of a
prolapsed cord after an amniotomy, the first action is to check the fetal heart rate for
signs of nonreassuring fetal heart rate patterns.
Level of Cognitive Ability: Analyzing
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: Lowdermilk et al. (2016), p. 783.

236. Answer: 2

Rationale: The birth process expends a great deal of energy, particularly during
the transition stage. Encouraging rest between contractions conserves maternal
energy, facilitating voluntary pushing efforts with contractions. Uteroplacental
perfusion also is enhanced, which promotes fetal tolerance of the stress of labor.
Ambulation is encouraged during early labor. Ice chips should be provided.
Changing positions frequently is not the primary physiological need. Food and
fluids are likely to be withheld at this time.
Test-Taking Strategy: Note the strategic word, primary. Also, noting the words
pushing effectively will assist in directing 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: Clinical Judgment; Reproduction
Reference: McKinney et al. (2018), pp. 357, 370.

237. Answer: 2

Rationale: The priority nursing action is to stop the infusion of oxytocin. Oxytocin
can cause forceful uterine contractions and decrease oxygenation to the placenta,
resulting in decreased variability. After stopping the oxytocin, the nurse should
reposition the laboring mother. Notifying the primary health care provider, applying
oxygen, and increasing the rate of the intravenous (IV) fluid (the solution without
the oxytocin) are also actions that are indicated in this situation, but not the priority
action. Contacting the client’s primary support person(s) is not the priority action at
this time.
Test-Taking Strategy: Focus on the strategic word, priority. Focus on the data in
the question and note the relationship of the words undergoing induction and the
correct option. Also recall that physiological needs are prioritized over psychosocial

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