NCLEX Question of The Day 37th Edition 2019 / 2020 / 2021
NCLEX Question of The Day 37th Edition 2019 / 2020 / 2021
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| NCLEX Question of The Day 37th Edition 2019 / 2020 / 2021 |
1. A client is undergoing electronic fetal monitoring (EFM), and the nurse informs the client about the procedure. Which statement indicates to the nurse that the client correctly understands this procedure?
A. “I’m getting tired of lying flat on my back.”
B. “How many volts of electricity are going through my body?”
C. “What an efficient way to record my baby’s heart rate.”
D. “I shut the machine off when I talk on the telephone.”
Answer: C. “What an efficient way to record my baby’s heart rate.”
Rationale: EFM is a method of recording the fetal heart rate. The woman is asked to assume a semi-sitting position or a lateral position when undergoing this procedure. The ultrasound transducer acts through the reflection of high-frequency sound waves from a moving interface, in this case, the fetal heart and valves. No electricity or voltage passes through the body.
Test-Taking Strategy: Use the process of elimination. Note the relation of the words “fetal monitoring” in the question and “baby’s heart rate” in the correct option. Review electronic fetal monitoring (EFM) if you had difficulty with this question.
Level of Cognitive Ability: Comprehension
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Maternity/Intrapartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 74-75.
2. A nurse is assisting in caring for a pregnant client who is on continuous fetal monitoring, and the nurse is asked to obtain a fetal monitor strip. Which of the following are the most important data for the nurse to document on the strip?
A. A temporary interruption in recording
B. Maternal vital signs
C. Last menstrual period
D. Age of client
Answer: B. Maternal vital signs
Rationale: Maternal vital signs can influence circulatory exchange with the placenta. Fetal oxygenation depends on a normal flow of oxygenated maternal blood into the placenta and normal uteroplacental exchange. A temporary interruption is noteworthy but not as important as option 2, which is the correct option. Options 3 and 4 are irrelevant data.
Test-Taking Strategy: Note the words “most important.” Use the ABCs—airway, breathing, and circulation. Vital signs reflect airway, breathing, and circulation. Review the procedures related to continuous fetal monitoring if you had difficulty with this question.
Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Communication and Documentation
Content Area: Maternity/Intrapartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 75.
3. A client tells the nurse that her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, “I can’t take it anymore.” Considering the client’s behavior, the nurse suspects she is dilated:
A. 1 to 2 cm
B. 3 to 4 cm
C. 5 to 7 cm
D. 8 to 10 cm
Answer: D. 8 to 10 cm
Rationale: During the transition phase of the first stage of labor, cervical dilation progresses from 8 to 10 cm. As contractions intensify, women often doubt their ability to cope with labor and fear abandonment.
Test-Taking Strategy: Focus on the data provided in the question. The question asks you to determine the phase of labor (transition) based on characteristic behaviors observed. Remember, the longer labor has progressed, the more likely the behaviors identified in the question will be observed. Therefore the greatest cervical dilation, 8 to 10 cm, is the correct option. Review the transition phase of labor 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
References:
- Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 145.
- Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 91.
4. A nurse is assisting in performing Leopold’s maneuvers. When the client asks what these are for, the nurse’s best response is that these maneuvers help to determine:
A. Duration of contractions
B. Fetal heart rate
C. Fetal position
D. Frequency of contractions
Answer: C. Fetal position
Rationale: Leopold’s maneuvers are a systematic way to evaluate the maternal abdomen using inspection and palpation to determine fetal position and presentation. Options 1, 2, and 4 are incorrect.
Test-Taking Strategy: Use the process of elimination. Note the similarity between options 1, 2, and D. These data could all be provided by a fetal monitor. Review Leopold’s maneuvers 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: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 106-107.
5. A nurse assists the nurse midwife to examine the client. The midwife documents the following data: cervix 80% effaced and 3 cm dilated, vertex presentation −2 station, membranes ruptured. The nurse anticipates that the midwife will prescribe which of the following activity orders for the client?
A. Ambulation
B. Bathroom privileges
C. Complete bed rest
D. Up in chair
Answer: C. Complete bed rest
Rationale: Rupture of the membranes with the presenting part not engaged and firmly down against the cervix can increase the risk of prolapsed cord. Activity and the downward force of gravity with the client upright can also increase the risk. Options 1, 2, and 4 are incorrect activity prescriptions.
Test-Taking Strategy: Use the process of elimination. Note that options 1, 2, and 4 are similar and promote activity. Option 3 promotes no activity, reduces the risk of prolapsed cord, and is the correct option. Review care to the client in labor if you had difficulty with this question.
Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Maternity/Intrapartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 247-248.
Source : NCLEX example quiz and answer
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