Nursing NCLEX Questions Quiz with Answer and Rationale 7th Edition (Maternity)

Nursing NCLEX Questions Quiz with Answer and Rationale 7th Edition (Maternity)

1. A nurse is reading the physician’s documentation regarding a pregnant client and notes that the physician has documented that the client has an android pelvic shape.

The nurse understands that this pelvic shape is:

A. Rounded and most favorable for a vaginal birth
B. Narrow and oval and not the most favorable for a vaginal birth
C. Wedge-shaped and narrow and nonfavorable for a vaginal birth
D. Flat and nonfavorable for a vaginal birth

Answer: C. Wedge-shaped and narrow and nonfavorable for a vaginal birth

Rationale: The android pelvic shape is wedge-shaped and narrow and is a nonfavorable shape for a vaginal birth. A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable pelvic shape for a vaginal birth. An anthropoid pelvic shape is long, narrow, and oval. It is not as favorable of a shape for a vaginal birth as the gynecoid pelvic shape; however, it is a more favorable pelvic shape than the platypelloid or android. The platypelloid pelvic shape is flattened with a wide, short oval shape and is also a nonfavorable shape for a vaginal birth.
Test-Taking Strategy: Focus on the issue—an android pelvic shape. Recalling that an android pelvic shape is wedge-shaped and narrow will direct you to option 3. If you had difficulty with this question, review the characteristics of the various pelvic shapes.
Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Maternity/Antepartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 14.

2. The physician prescribes laboratory studies on an infant of a human immunodeficiency virus (HIV) positive woman to determine the presence of HIV infection.

Which laboratory study would the nurse expect to be prescribed?

A. Western blot
B. Chest x-ray
C. CD4 count
D. p24 antigen assay

Answer: D. p24 antigen assay

Rationale: True HIV infection in the infant is confirmed by a p24 antigen assay, a culture of HIV, or a polymerase chain reaction (PCR). A Western blot confirms the presence of HIV antibodies. The CD4 count indicates how well the immune system is working. A chest x-ray evaluates the presence of other manifestations of HIV infection.
Test-Taking Strategy: Focus on the issue—the presence of HIV infection in an infant. Remember, true HIV infection in the infant is confirmed by a p24 antigen assay, a culture of HIV, or a polymerase chain reaction (PCR). If you are unfamiliar with these laboratory studies, review this content. Specific laboratory tests to review include the enzyme-linked immunosorbent assay (ELISA), Western blot, CD4 counts, and p24 antigen assay.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Child Health
Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 80.

3. A nurse is measuring the fundal height of a client who is 30-weeks gestation. In preparing to perform the procedure the nurse would:

A. Turn the client onto her left side
B. Instruct the client to lie in a prone position
C. Place the client in a prone position with the head of the bed elevated
D. Have the client stand for the procedure

Answer: A. Turn the client onto her left side

Rationale: When measuring fundal height, the client lies in a supine position and the nurse instructs the woman to turn onto her left side. The nurse then elevates the left buttock by placing a pillow under the area. This position will assist in preventing supine hypotension. Options 2, 3, and 4 are incorrect client positions for measuring fundal height.
Test-Taking Strategy: Focus on the issue of the question and think about the physiological effects of an enlarged uterus at 30 weeks of gestation. Eliminate options 2 and 3 first because they are similar. From the remaining options, recalling the potential for supine hypotension or by knowing that the standing position is inappropriate for measuring fundal height will assist in directing you to option 1. Review the procedure for measuring fundal height 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/Antepartum
Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 416.

4. A nurse is assisting in conducting a childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the woman to perform the procedure by:

A. Contracting and then consciously relaxing different muscle groups
B. Contracting an area of the body such as an arm or leg and then concentrating or letting tension go from the rest of the body
C. Massaging the abdomen during contractions using both hands in a circular motion
D. Instructing the significant other to stroke or massage a tightened muscle by the use of touch

Answer: C. Massaging the abdomen during contractions using both hands in a circular motion

Rationale: Effleurage is massage of the abdomen during contractions. Women learn to do effleurage using both hands in a circular motion. Progressive relaxation involves contracting and then consciously releasing different muscle groups. Neuromuscular disassociation helps the woman relax her body even when one group of muscles is strongly contracted. In this procedure the woman contracts an area such as an arm or leg and then concentrates on letting tension go from the rest of the body. Touch relaxation helps the woman learn to loosen taut muscles when they are touched by her partner.
Test-Taking Strategy: Use the process of elimination, focusing on the issue—effleurage. Remember, effleurage is massage of the abdomen during contractions. If you had difficulty with this question or are unfamiliar with this cutaneous stimulation technique, review this content.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Teaching/Learning
Content Area: Maternity/Antepartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 65.

5. A clinic nurse is planning care to meet the emotional needs of a pregnant woman. Which nursing intervention would least likely assist in meeting emotional needs?

A. Providing an opportunity for the pregnant woman to discuss the aspects of pregnancy
B. Using a caring and supportive approach when dealing with the pregnant woman
C. Offering praise and reinforcement for compliance with treatment therapies
D. Providing the mother with pamphlets and booklets to read about the pregnancy

Answer: D. Providing the mother with pamphlets and booklets to read about the pregnancy

Rationale: The woman’s emotional needs can be met by providing regular opportunities for discussing aspects of her pregnancy and prenatal care, by using a caring and supportive approach, and by offering praise and reinforcement. The nurse should also discuss the emotional changes of pregnancy, family alterations, and changes in marital relationships that may occur. Option 4 will least likely assist in meeting the emotional needs of the woman.
Test-Taking Strategy: Note the key words least likely in the stem of the question. Note that options 1, 2, and 3 are similar in that they identify interventions that are both positive and deal directly with the client. Option 4 promotes the use of materials for the client to read on her own. Review the methods that will assist in meeting the emotional needs of a pregnant woman if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Planning
Content Area: Maternity/Antepartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 51, 229.

Source : NCLEX example quiz and answer

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