Example of NCLEX RN Question with Answer and Rationale 16th Edition
Example Exam of NCLEX RN Question with Answer and Rationale 16th Edition
1. The nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1:8. Which of the following would the nurse anticipate to be prescribed by the physician?
A. A repeat rubella titer in 2 weeks
B. Administration of a subcutaneous rubella virus vaccine
C. Administration of a subcutaneous rubella virus vaccine for the newborn
D. Counseling to the mother and informing the mother that this is a normal titer
Answer: B. Administration of a subcutaneous rubella virus vaccine
Rationale: A blood sample for rubella titer is done on all women in the antepartum or postpartum period. A woman with a titer of 1:8 or less should receive a subcutaneous rubella virus vaccine (Meruvax II). This stimulates active immunity against the rubella virus. The woman should be counseled to avoid pregnancy for 3 months after receiving the vaccine.
Test-Taking Strategy: Knowledge regarding the expected titer results for rubella is required to answer this question. Recalling that a titer of 1:8 or less requires the administration of a subcutaneous rubella virus vaccine to the mother will direct you to option B. If you are unfamiliar with this titer, review this content.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 211.
2. A postpartum client asks the nurse when she can resume sexual activity. The nurse tells the client that sexual activity can:
A. Be resumed at any time
B. Not be resumed until the 8-week physician checkup
C. Be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped
D. Be resumed after a normal menstrual period begins
Answer: C. Be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped
Rationale: It is recommended that women refrain from sexual intercourse until the episiotomy has healed and the lochia has stopped. This process usually takes about 3 weeks. Options 1, 2, and 4 are inaccurate.
Test-Taking Strategy: Knowledge regarding instructions to the mother regarding sexual activity following birth and delivery is needed to answer this question. Remember, sexual activity can be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped. If you had difficulty with this question, review this content.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Teaching/Learning
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 207.
3. A nurse is monitoring a client for signs of postpartum depression. Which of the following if noted in the new mother would indicate the need for further assessment related to this form of depression?
A. The mother is caring for the infant in a loving manner
B. The mother constantly complains of tiredness and fatigue
C. The mother demonstrates an interest in the surroundings
D. The mother looks forward to visits from the father of the newborn
Answer: B. The mother constantly complains of tiredness and fatigue
Rationale: Postpartum depression is not the normal depression that many new mothers experience from time to time. The woman experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The woman is also unable to show pleasure or love, and may have intense feelings of unworthiness, guilt, and shame. The woman often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty in concentrating are also present. The mother would have little interest in food and experience sleep disturbances.
Test-Taking Strategy: Note the key words need for further assessment. Use the process of elimination, noting that options 1, 3, and 4 identify positive maternal behaviors. If you had difficulty with this question, review the clinical manifestations of postpartum depression.
Level of Cognitive Ability: Analysis
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 199.
4. A nurse is caring for a client who delivered a healthy newborn via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the mother regarding care related to the infection. Which statement by the mother indicates a need for further instructions?
A. “I need to take the antibiotics as prescribed.”
B. “I need to apply warm compresses to provide comfort.”
C. “I need to take warm sitz baths to promote healing.”
D. “I need to isolate my infant for 48 hours after starting the antibiotics.”
Answer: D. “I need to isolate my infant for 48 hours after starting the antibiotics.”
Rationale: Broad-spectrum antibiotics will be prescribed for the mother, and the mother should be instructed to take the antibiotics as prescribed. Analgesics are often necessary, and warm compresses or sitz baths may be used to provide comfort in the area. The infant is not routinely isolated from the mother with a wound infection, but the mother must be taught how to protect the infant from contact with contaminated articles.
Test-Taking Strategy: Use the process of elimination, noting the key words need for further instructions. Eliminate options 2 and 3 first because they are similar. From the remaining options, knowing that the infant does not need to be isolated from the mother will assist in directing you to the correct option. Review care to the client with a wound infection from an episiotomy site if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 292-293.
5. A nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse avoids including which incorrect intervention in the plan of care?
A. Elevating the affected extremity
B. Maintaining bed rest
C. Applying warm pads to the affected area
D. Administering the prescribed anticoagulants
Answer: D. Administering the prescribed anticoagulants
Rationale: Thrombosis that is limited to the superficial veins of the saphenous system is treated with analgesics, rest, and elastic support stockings. Elevation of the lower extremity improves venous return and may also be recommended. Warm packs may be applied to the affected area to promote healing. There is no need for anticoagulants or antiinflammatory agents unless the condition persists. After 5 to 7 days of bed rest, and when symptoms disappear, the woman may gradually begin to ambulate.
Test-Taking Strategy: Note the key words avoids and incorrect. These key words indicate a false response question and that you need to select the incorrect intervention. Also note the word “superficial” and focus on the diagnosis. Recalling that anticoagulants are not used to treat superficial venous thrombosis will assist in directing you to option D. Review therapeutic management of superficial venous thrombosis if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 243.
Thank you for your attention with reading our article Example Exam of NCLEX RN Question with Answer and Rationale 16th Edition (Maternity/intrapartum/Postpartum). Thanks for your participation, like and share if this is usefull.
0 Response to "Example of NCLEX RN Question with Answer and Rationale 16th Edition"
Post a Comment