Page 771 - Saunders Comprehensive Review For NCLEX-RN

and oxytocin infusion are not treatment measures for hypertonic contractions;
however, these treatments may be used in clients with hypotonic dysfunction. A
client with hypertonic uterine contractions would not be encouraged to ambulate
every 30 minutes but would be encouraged to rest.
Test-Taking Strategy: Focus on the strategic word, priority. Also note that options
2, 3, and 4 are comparable or alike and are therapeutic measures for hypotonic
dysfunction.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Maternity: Intrapartum
Health Problem: Maternity: Dystocia
Priority Concepts: Clinical Judgment; Pain
Reference: McKinney et al. (2018), pp. 574-575.

242. Answer: 3

Rationale: Vaginal examinations should not be done routinely on a client with
premature rupture of the membranes because of the risk of infection. The nurse
would expect to monitor fetal heart rate, monitor maternal vital signs, and
administer an antibiotic.
Test-Taking Strategy: Note the word question. This word indicates the activity that
the nurse should not implement without clarification. Options 1, 2, and 4 are
comparable or alike and are expected activities for the nurse to perform for a client
with premature rupture of the membranes. Performing a vaginal examination every
shift should not be done on a client with premature rupture of the membranes
because of the risk of infection, so the nurse would question this prescription.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Maternity: Intrapartum
Health Problem: Maternity: Premature rupture of the membranes
Priority Concepts: Collaboration; Safety
Reference: McKinney et al. (2018), pp. 580-581.

243. Answer: 2

Rationale: Dystocia is difficult labor that is prolonged or more painful than
expected. The priority is to monitor the fetal heart rate. Although providing comfort
measures, changing the client’s position frequently, and keeping the significant other
informed of the progress of the labor are components of the plan of care, the fetal
status would be the priority.
Test-Taking Strategy: Note the strategic word, priority. Use Maslow’s Hierarchy
of Needs theory and the ABCs—airway, breathing, and circulation—to assist in
answering the question. These strategies will direct you to the correct option.
Level of Cognitive Ability: Creating
Client Needs: Physiological Integrity

771