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Question and Answer NCLEX with Rationale 11th Edition 2019 / 2020
1. A nurse is instructing a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the mother indicates an understanding of the daily fluid requirement?
A. “I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement.”
B. “I should drink 8 to 12 glasses of liquid a day and I can count the tea, fruit juices, or milk that I drink.”
C. “I should drink 8 to 12 glasses of liquid a day and I can count the carbonated soft drinks that I consume.”
D. “I should drink 8 to 12 glasses of liquid a day and can count the coffee that I drink.”
Answer: A. “I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement.”
Rationale: The nurse should instruct the client to drink an adequate fluid intake on a daily basis to assist in digestion and in the management of constipation. Eight to twelve glasses of liquids (1500 to 2000 mL) in addition to the daily milk requirement are recommended every day. This fluid should be water or fruit and vegetable juices rather than carbonated soft drinks or caffeinated beverages.
Test-Taking Strategy: Use the process of elimination. Recalling that carbonated soft drinks and caffeine-containing products should be avoided will assist in eliminating options 2, 3, and D. Remember that milk requirements are not included in the total fluid intake of 1500 to 2000 mL. This will direct you to option A. If you had difficulty with this question, review client instructions regarding water and fluid intake during pregnancy.
Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Antepartum References:
Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 8-10.
Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 63.
2. A nurse is instructing a pregnant client how to increase dietary sources of iron. The nurse tells the client that which food is the highest source of dietary iron?
A. Milk
B. Dark-green leafy vegetables
C. Potatoes
D. Cantaloupe
Answer: B. Dark-green leafy vegetables
Rationale: Dietary sources of iron include lean meats, liver, shellfish, dark-green leafy vegetables, legumes, whole grains and enriched grains, cereals, and molasses. Milk is high in calcium and also contains phosphorus. Cantaloupe and potatoes are high in vitamin C.
Test-Taking Strategy: Use the process of elimination and knowledge of the dietary sources of iron to assist in answering the question. Remember, dark-green leafy vegetables are high in iron. If you had difficulty with this question, review the food items high in iron.
Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 60.
3. A nurse has instructed a postpartum client who is hepatitis B positive how to safely bottle-feed her newborn to prevent the transmission of the infection. Which action by the client indicates an understanding of this procedure?
A. Tests the temperature of the formula before initiating feeding
B. Holds the infant properly during feeding and burping
C. Washes and dries her hands before feeding
D. Requests that the window be closed before feeding
Answer: C. Washes and dries her hands before feeding
Rationale: Hepatitis B virus (HBV) is highly contagious by direct contact with blood and body fluids of infected persons. Strict hand washing before contact with the newborn will assist in preventing the transmission of infection. Options 1 and 2 are appropriate feeding techniques for bottle-feeding, but do not minimize disease transmission for hepatitis B. Option 4 will not affect disease transmission.
Test-Taking Strategy: Focus on the issue of the question—disease transmission to the newborn. This focus and the process of elimination will direct you to option C. Review measures to prevent disease transmission of hepatitis if you had difficulty with this question.
Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 160.
4. The pregnant client who is anemic tells the nurse that she is concerned about her baby’s condition following delivery. The nurse makes which statement that will best address the client’s concern?
A. “You will not have any problems if you follow all the advice the doctor has given you.”
B. “Your baby will need to spend a few days in the neonatal intensive care unit following delivery.”
C. “Don’t worry about your baby; complications are rare.”
D. “The effects of anemia on your baby are difficult to predict, but let’s review your plan of care to assure you are providing the best nutrition and growth potential.”
Answer: D. “The effects of anemia on your baby are difficult to predict, but let’s review your plan of care to assure you are providing the best nutrition and growth potential.”
Rationale: The effects of maternal iron-deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have been reported to experience reduced red cell volume, hemoglobin levels, and iron stores. Options 1 and 3 provide a false reassurance to the client. Option 2 will cause further concern in the client. Option 4 provides the most realistic support for the client and allows the nurse an opportunity to review the client’s plan of care to clarify information and reassure the mother.
Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques to answer the question. Eliminate options 1 and 3 because these statements provide a false reassurance to the client. Eliminate option 2 next because this statement will cause further concern in the client. If you had difficulty with this question, review therapeutic communication techniques and the effects of maternal anemia on the fetus.
Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Maternity/Postpartum References:
Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 107.
Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 225.
McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 30-31.
5. A nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily to:
A. Help the mother prepare for labor and delivery
B. Reduce excessive maternal stress and fatigue
C. Prepare the 18-month-old child for maternal separation during hospitalization
D. Avoid exposure to potential pathogens and resulting infections
Answer: B. Reduce excessive maternal stress and fatigue
Rationale: A variety of factors can cause increased emotional stress during pregnancy resulting in further cardiac complications. The client with known cardiac disease is at greater risk for such complications. Use of appropriate resources will assist the client to avoid emotional stress, thus reducing additional cardiac compromise during the last trimester. Options 1, 3, and 4 are not primary purposes for use of resources with the pregnant cardiac client.
Test-Taking Strategy: Focus on the issue of the question noting the client’s diagnosis. Also noting the key word primarily in the stem of the question will assist in directing you to option B. Review considerations in caring for the pregnant client with cardiac disease if you had difficulty with this question.
Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 225
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