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Example Nursing Question for NCLEX RN with Answer 39th Edition
1. A nurse tells the client she is now beginning the second stage of labor. The nurse realizes the client understands the developments in this stage when the client says:
A. “I’m having a backache.”
B. “My cervix is completely dilated.”
C. “My membranes just ruptured.”
D. “The contractions are very mild.”
Answer: B. “My cervix is completely dilated.”
Rationale: The second stage of labor begins when the cervix is completely dilated and ends with birth of the infant. Option 1 can occur any time during labor. Options 3 and 4 are characteristics of early labor.
Test-Taking Strategy: Knowledge regarding the description related to the second stage of labor is required to answer this question. Remember, the second stage of labor begins when the cervix is completely dilated. If you had difficulty with this question, review this stage of labor.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Maternity/Intrapartum
Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 583.
2. A client delivers a viable male neonate who is given Apgar scores of 8 and 9 at 1 and 5 minutes. The nurse determines the physical condition of the neonate to be:
A. Critical
B. Poor
C. Fair
D. Good
Answer: D. Good
Rationale: The Apgar scoring system was designed to evaluate the physical condition of the newborn at birth and determine the immediate need for resuscitation. Scores range from 0 to 10. A score of 8 to 10 indicates a newborn in good condition.
Test-Taking Strategy: Use the process of elimination and knowledge of the Apgar scoring system. Options 1, 2, and 3 are similar, indicating that additional intervention would be required. Option 4 is different. Review Apgar scoring if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Maternity/Intrapartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 153.
3. A client has just delivered a viable newborn. The first nursing action to initiate attachment is to:
A. Complete routine newborn care measures quickly
B. Determine the parents’ desires for contact with the newborn
C. Encourage immediate breast-feeding
D. Suggest the mother hold the newborn after the placenta is delivered
Answer: B. Determine the parents’ desires for contact with the newborn
Rationale: Although immediate contact may be important for attachment or breast-feeding, the parents’ wishes concerning contact with their newborn need to be supported and determined first.
Test-Taking Strategy: Note the key word first. Use the steps of the clinical problem-solving process (nursing process), recalling that data collection is the first step. Option 2 reflects data collection. Review the concepts of parental-newborn attachment if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Intrapartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 207.
4. In providing initial care of the newborn following delivery, the priority action of the nurse is to:
A. Identify gestational age
B. Identify the infant and mother
C. Turn the infant’s head to the side
D. Record the number of umbilical vessels
Answer: C. Turn the infant’s head to the side
Rationale: The priority is to maintain an open airway. Turning the infant’s head to the side will aid the drainage of mucus from the nasopharynx and trachea to facilitate breathing. Options 1, 2, and 4 are appropriate but can be implemented later.
Test-Taking Strategy: Use the principles of prioritization and the ABCs—airway, breathing, and circulation. Option 3 is correct because this position facilitates drainage of mucus and promotes an open airway and effective breathing. Review initial care of the newborn if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Intrapartum
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 555.
5. A nurse is assigned to care for a client 1 hour after delivery. The nurse palpates a firm, uterine fundus 2 cm above the umbilicus and displaced to the right. The nurse recognizes that this finding may indicate:
A. Bladder distention
B. Endometrial infection
C. Retained placental fragments
D. Uterine atony
Answer: A. Bladder distention
Rationale: Immediately following expulsion of the placenta, the fundus is firmly contracted, midline, and located one half to two thirds of the way between the symphysis pubis and umbilicus. Because the uterine ligaments are still stretched, a full bladder can move the uterus. Options 2, 3, and 4 are complications not usually indicated by a firm and displaced uterus.
Test-Taking Strategy: Knowledge regarding the physiological findings in the postpartum period is required to answer this question. Visualizing the data in the question and noting the words “displaced to the right” will direct you to the correct option. If you had difficulty with this question, review care to the client in the postpartum period.
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, p. 197.
Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.) St. Louis: Mosby, p. 631.
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