Page 883 - Saunders Comprehensive Review For NCLEX-RN

medications in the options and that betamethasone is used to increase the
production of surfactant will direct you to the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Analysis
Content Area: Pharmacology: Maternity/Newborn: Lung Surfactant
Health Problem: Maternity: Preterm Labor
Priority Concepts: Gas Exchange; Perfusion
Reference: McKinney et al. (2018), p. 588.

288. Answer: 2

Rationale: Methylergonovine, an ergot alkaloid, is used to prevent or control
postpartum hemorrhage by contracting the uterus. Methylergonovine causes
continuous uterine contractions and may elevate the blood pressure. A priority
assessment before the administration of the medication is to check the blood
pressure. The obstetrician needs to be notified if hypertension is present. Although
options 1, 3, and 4 may be components of the postpartum assessment, blood
pressure is related specifically to the administration of this medication.
Test-Taking Strategy: Note the strategic word, priority. Eliminate options 1 and 3
first because they are comparable or alike and related to one another. To choose
from the remaining options, use the ABCs—airway, breathing, and circulation.
Blood pressure is a method of assessing circulation.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Pharmacology: Maternity/Newborn: Ergot alkaloids
Health Problem: Maternity: Postpartum uterine problems
Priority Concepts: Clotting; Reproduction
Reference: McKinney et al. (2018), p. 601.

289. Answer: 2

Rationale: Respiratory distress syndrome is a serious lung disorder caused by
immaturity and the inability to produce surfactant, resulting in hypoxia and
acidosis. It is common in premature infants and may be due to lung immaturity as a
result of surfactant deficiency. The mainstay of treatment is the administration of
exogenous surfactant, which is administered by the intratracheal route. Options 1, 3,
and 4 are not routes of administration for this medication.
Test-Taking Strategy: Focus on the subject, route of administration for exogenous
surfactant. Note the relationship between the diagnosis, respiratory distress syndrome,
and the correct option, intratracheal.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Planning
Content Area: Pharmacology: Maternity/Newborn: Lung Surfactant
Health Problem: Newborn: Respiratory Problems

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