NCLEX RN Questions and Answers with Rationale 2019, 2020, 2021 14th Edition
NCLEX RN Questions and Answers with Rationale 2019, 2020, 2021 14th Edition
1. A nurse is assisting to care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by:
A. Placing the external fetal monitor over the fetus that is most anterior to the mother’s abdomen
B. Placing the external fetal monitor over the fetus that is most posterior to the mother’s abdomen
C. Placing external fetal monitors so that each fetal heart rate is monitored separately
D. Placing the fetal monitor so that one fetus is monitored for a 15-minute period followed by a 15-minute fetal monitoring period for the second fetus
Answer: C. Placing external fetal monitors so that each fetal heart rate is monitored separately
Rationale: In a client with a multifetal pregnancy, each fetal heart rate is monitored separately. Options 1, 2, and 4 are incorrect because these actions would not provide information regarding the status of each fetus.
Test-Taking Strategy: Use the process of elimination and knowledge regarding the monitoring of fetal status in a multifetal pregnancy. Note that options 1, 2, and 4 are similar in that they all relate to monitoring only one fetus at one time. Review care to the client with a multifetal pregnancy if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Maternity/Intrapartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 194.
2. A nurse in the delivery room is assisting with the delivery of a newborn. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery?
A. Shortening length and changing color in the umbilical cord
B. A soft and boggy uterus
C. Maternal complaints of severe uterine cramping
D. Changes in the shape of the uterus
Answer: D. Changes in the shape of the uterus
Rationale: Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to globular shape. The client may experience vaginal fullness, but not severe uterine cramping.
Test-Taking Strategy: Use the process of elimination. Recalling that the placenta is attached to the uterine wall will assist in directing you to option D. Review the findings associated with placental separation if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Intrapartum
Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.) St. Louis: Mosby, p. 596.
3. A nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red in color and has a foul-smelling odor. The nurse determines that this finding indicates:
A. A normal finding
B. The presence of infection
C. The need for increased oral fluids
D. The need for increased ambulation
Answer: B. The presence of infection
Rationale: Lochia, the discharge present after birth, is red in color the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor similar to the odor that is present during menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. Encouraging the woman to drink fluids or ambulate are not accurate interpretations related to the assessment finding.
Test-Taking Strategy: Use the process of elimination, noting the key words foul-smelling. These key words should direct you to option B. If you had difficulty with this question, review normal assessment findings of lochia in the postpartum woman.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Postpartum
References:
- Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 206-207.
- Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 194.
4. A nurse in the postpartum unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed:
A. 1 pad a day
B. 2 pads a day
C. 3 pads a day
D. 8 pads a day
Answer: D. 8 pads a day
Rationale: The normal amount of lochia may vary with the individual but should never exceed 4 to 8 pads a day. The average number of pads used daily is 6.
Test-Taking Strategy: Use the process of elimination. Focusing on the key words should never exceed will assist in directing you to option D. If you had difficulty with this question, review postpartum assessment.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Teaching/Learning
Content Area: Maternity/Postpartum
References:
- Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 193-194.
- Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 630.
5. A nurse is collecting data on a client who is 6-hours postpartum following delivery of a full-term healthy newborn. The client tells the nurse that she feels faint and dizzy. Which nursing action would be appropriate?
A. Obtain a hemoglobin and hematocrit level
B. Instruct the mother to request help when getting out of bed
C. Elevate the head of the bed
D. Inform the nursery room nurse to avoid bringing the newborn to the mother until the feelings of light-headedness and dizziness have subsided
Answer: B. Instruct the mother to request help when getting out of bed
Rationale: Orthostatic hypotension may occur during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to be aware of the client’s safety. The nurse should advise the mother to get help the first few times the mother gets out of bed. Option 1 requires a physician’s order. Option 3 is not a helpful action. Option 4 is unnecessary.
Test-Taking Strategy: Use the process of elimination and focus on the issue of the question—client safety. Option 4 is inappropriate and should be eliminated first. Elevating the head of the bed is not a helpful nursing intervention to treat these symptoms. From the remaining options, recall that safety is a primary issue. This should assist in directing you to the correct option. If you had difficulty with this question, review postpartum nursing interventions.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Postpartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 201.
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