Page 772 - Saunders Comprehensive Review For NCLEX-RN

Integrated Process: Nursing Process—Planning
Content Area: Maternity: Intrapartum
Health Problem: Maternity: Dystocia
Priority Concepts: Clinical Judgment; Perfusion
Reference: Lowdermilk et al. (2016), pp. 773-774.

244. Answer: 4

Rationale: Oxygen is administered, 8 to 10 L/minute, via face mask to optimize
oxygenation of the circulating blood. Option 1 is incorrect, because the intravenous
infusion should be increased (per primary health care provider prescription) to
increase the maternal blood volume. Option 2 is incorrect, because oxytocin
stimulation of the uterus is discontinued if fetal heart rate patterns change for any
reason. Option 3 is incorrect because the client is placed in the lateral position with
her legs raised to increase maternal blood volume and improve fetal perfusion.
Test-Taking Strategy: Note the strategic words, most important. Use the ABCs—
airway, breathing, and circulation. Oxygen is the only option that would improve
cardiac output and improve perfusion to the fetus. The other options would not
improve perfusion to the fetus.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Complex Care: Emergency Situations/Management
Health Problem: Maternity: Fetal distress/Demise
Priority Concepts: Clinical Judgment; Perfusion
Reference: McKinney et al. (2018), p. 344.

245. Answer: 2

Rationale: When cord prolapse occurs, prompt actions are taken to relieve cord
compression and increase fetal oxygenation. The client should be positioned with the
hips higher than the head to shift the fetal presenting part toward the diaphragm.
The nurse should push the call light to summon help, and other staff members
should call the primary health care provider and notify the delivery room. If the cord
is protruding from the vagina, no attempt should be made to replace it because to do
so could traumatize it and reduce blood flow further. Also as a first action, the
examiner should place a gloved hand into the vagina and hold the presenting part
off the umbilical cord. Oxygen, 8 to 10 L/minute, by face mask is administered to the
client to increase fetal oxygenation.
Test-Taking Strategy: Note the strategic word, first, and that the umbilical cord is
protruding from the vagina. Options 3 and 4 can be eliminated first because these
actions delay necessary and immediate treatment. Recalling that the goal is to relieve
cord compression and to increase fetal oxygenation will direct you to the correct
option. Also remember that the cord should not be pushed back into the vagina.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation

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