Example NCLEX Practice Questions With Answer 2019 / 2020 / 2021 35th Edition
Example NCLEX Practice Questions With Answer 2019 / 2020 / 2021 35th Edition
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| Example NCLEX Practice Questions With Answer 2019 / 2020 / 2021 35th Edition |
1. A nurse is caring for a woman who has delivered a baby after a pregnancy with a placenta previa. The nurse monitors the client frequently, knowing that the client is at risk for:
A. Postpartum hemorrhage
B. Chronic hypertension
C. Postpartum infection
D. Coagulopathy
Answer: A. Postpartum hemorrhage
Rationale: Because the placenta is implanted in the lower uterine segment that does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding. The nurse monitors the client frequently for signs of postpartum hemorrhage. Options 2, 3, and 4 are not directly associated with placenta previa.
Test-Taking Strategy: Use the process of elimination and knowledge regarding the complications associated with placenta previa. Also, recalling the pathophysiology associated with placenta previa will direct you to option A. Review the complications associated with placenta previa if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 216.
2. A nurse is assisting in planning care for a client with a diagnosis of placenta previa. The nurse identifies which of the following as the priority goal for the client?
A. Client exhibits no signs of fetal distress
B. Client expresses an understanding of her condition
C. Client identifies and uses available support systems
D. Client demonstrates compliance with activity limitations
Answer: A. Client exhibits no signs of fetal distress
Rationale: Option 1 clearly identifies a physiological need. Options 2, 3, and 4 may be a component of the plan of care, but the physiological integrity and safety of the mother/newborn dyad is the priority.
Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory. Options 2, 3, and 4 deal with the psychosocial aspects of care while option 1 deals with physiological and safety issues. Review care to the client with placenta previa if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Delegating/Prioritizing
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 216.
3. A client had a cesarean delivery with a low transverse uterine incision. The nurse explains the benefits of this type of incision to the client knowing that this type of incision:
A. Allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy
B. Can be extended if a larger incision is needed
C. Is the best choice with a placenta previa on the lower anterior uterine wall
D. Requires that a vertical skin incision be made
Answer: A. Allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy
Rationale: A low transverse uterine incision is unlikely to rupture during a subsequent labor and is the only type of uterine incision considered safe for a subsequent VBAC delivery. It cannot be extended laterally because of the location of the major uterine blood vessels in the lower uterine segment. In the presence of a placenta previa, a classic incision into the body of the uterus would be needed to prevent incising into the placental area. A suprapubic skin incision can be made with a lower uterine transverse incision.
Test-Taking Strategy: Knowledge regarding the different types of skin and uterine incisions is needed to answer the question. Noting the key words low transverse will assist in directing you to option A. Review the types of uterine incisions if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 456-457.
4. A nurse is caring for a client scheduled for a cesarean delivery. The nurse reviews the client’s health record knowing that which finding needs to be further investigated before delivery?
A. Hemoglobin level of 11.5 g/dl
B. White blood cell count of 35,000 mm3
C. Maternal pulse rate of 90 beats per minute
D. Fetal heart rate of 154 beats per minute
Answer: B. White blood cell count of 35,000 mm3
Rationale: White blood cell counts in a normal pregnancy begin to rise in the second trimester and peak in the third trimester with a normal range of 11,000 to 15,000 mm3 up to 18,000 mmC. A count of 35,000 mm3 before delivery is abnormal and may indicate infection, which can complicate the delivery. By full term, a normal maternal hemoglobin range is 11 to 13 g/dl because of hemodilution caused by an increase in plasma volume during pregnancy. Maternal pulse rate during pregnancy increases 10 to 15 beats per minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. A normal fetal heart rate is 120 to 160 beats per minute.
Test-Taking Strategy: Note the key words needs to be further investigated. Use the process of elimination, noting that option 2 indicates an abnormal value. Review these laboratory values and the normal findings in pregnancy if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Intrapartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 255.
5. A client is scheduled to have an elective cesarean delivery. The nurse preparing the client for the procedure plans to allay the client’s feelings of anxiety by:
A. Emphasizing the technical aspects of this type of delivery
B. Deciding how soon the client should see the baby after delivery
C. Decreasing the partner’s anxiety by keeping him or her in the waiting area
D. Encouraging the client to discuss her concerns and desires regarding anesthesia options
Answer: D. Encouraging the client to discuss her concerns and desires regarding anesthesia options
Rationale: Emotional needs of the client and family are best met by assessing their feelings and allowing for verbalization of concerns. Options 1, 2, and 3 involve actions by the nurse, which do not involve client input. Those undergoing cesarean delivery often feel disappointment and guilt, even if the procedure is elective. Providing the opportunity for discussion and input into decisions can help to alleviate these feelings. Too much technical information may increase the client’s anxiety. The presence of a support person is helpful.
Test-Taking Strategy: Use the steps of the clinical problem-solving process (nursing process) to assist in answering the question. Remember that data collection is the first step. Additionally, option 4 focuses on the client’s feelings. Review the psychosocial aspects related to a cesarean delivery if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Caring
Content Area: Maternity/Intrapartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 250
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