NCLEX RN Examination (Example and Answer) 60th Edition

NCLEX RN Examination (Example and Answer) 60th Edition (Maternity / Antepartum Questions)

1. A pregnant client tells the nurse that she has been experiencing pain because of hemorrhoids. Which of the following statements by the client would identify the need for further teaching regarding hemorrhoids?

A. “Hemorrhoids are caused by the changes in hormones during pregnancy. They will go away after the baby is born.”
B. “Hemorrhoids are aggravated by standing for long periods of time. I need to lie down periodically during the day to relieve the pressure.”
C. “Hemorrhoids can be gently pushed back inside the body using a lubricant.”
D. “Diet is very important in the treatment of hemorrhoids. Plenty of liquids and a balance of bulk in the diet are needed.”

Answer: A. “Hemorrhoids are caused by the changes in hormones during pregnancy. They will go away after the baby is born.”

Rationale: Hemorrhoids are varicosities and are most likely to be precipitated during pregnancy by the pressure of the growing fetus inside the abdominal cavity. Standing aggravates the problem. Dietary factors, such as fluids and roughage, and the technique of manual reduction should be included in the plan of care. Hormonal changes are not a factor.

Test-Taking Strategy: Note the key words need for further teaching. These words indicate a false response question and that you need to select the incorrect client statement. Use knowledge regarding hemorrhoids to assist you in selecting the correct option. Review the causes of hemorrhoids during pregnancy if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Content Area: Maternity/Antepartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 69.

2. A client is a gravida IV, para III in her final trimester of pregnancy. She does not attend usual social functions due to the fear of stress incontinence. Her oldest child is in a school play, which she wants to attend. Which of the following is appropriate to suggest to the client?

A. Perform Kegel exercises during the play
B. Limit fluid intake to 500 mL on the day of the play
C. Wear a perineal pad to the play
D. Have a friend videotape the play for her

Answer: C. Wear a perineal pad to the play

Rationale: Kegel exercises are useful to promote long-term bladder tone, but will not be effective with 1 day’s use. Limiting fluid intake can be harmful. A videotape will not satisfy the client’s need to be present at the play. Wearing a perineal pad will give the client the security that she needs. The client should be instructed to remove a damp pad as soon as possible to decrease the incidence of urinary tract infection.

Test-Taking Strategy: Use the process of elimination, noting the key words she wants to attend. These key words will eliminate option D. From the remaining options, focus on physiological integrity while meeting a psychosocial need. Review the psychosocial needs of a pregnant client if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Antepartum
References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 279.
Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 40-41.

3. During a routine prenatal visit, a client complains of gingivitis and gums that bleed easily with brushing. When assisting to plan the care for the client, the nurse includes a goal that addresses proper nutrition to minimize this problem. The nurse determines that goal achievement has occurred when the client states which of the following?

A. “I am eating three servings of cracked wheat bread each day.”
B. “I am eating fresh fruits and vegetables for snacks and for dessert each day.”
C. “I am drinking 8 ounces of water with each meal.”
D. “I eat two saltine crackers before I get up each morning.”

Answer: B. “I am eating fresh fruits and vegetables for snacks and for dessert each day.”

Rationale: Fresh fruits and vegetables will provide vitamins and minerals needed for healthy gums. Eating cracked wheat bread may abrade the tender gums; drinking water with meals has no direct effect on gums; consuming saltine crackers before arising helps decrease nausea.

Test-Taking Strategy: Use the process of elimination. Focus on the issue of the question—gingivitis and gums that bleed easily. Eliminate options 1 and 4 because they could produce irritation to any fragile gums. From the remaining options, select option 2 because this option directly relates to the issue of the question. Review health care measures during pregnancy if you had difficulty with this question.

Level of Cognitive Ability: Analysis
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Evaluation
Content Area: Maternity/Antepartum
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 57.

4. A nurse is assigned to care for a pregnant client with a diagnosis of sickle cell anemia. The nurse plans care knowing that which of the following problems should receive highest priority?

A. Activity intolerance
B. Body image disturbance
C. Fear
D. Fluid volume deficit

Answer: D. Fluid volume deficit

Rationale: For the client with sickle cell anemia, dehydration will precipitate sickling of the red blood cells. Sickling can lead to life-threatening consequences for the pregnant woman and for the fetus, such as an interruption of blood flow to the respiratory system and placenta. Although options 1, 2, and 3 may be components of the plan of care, fluid volume deficit is the priority.

Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory to prioritize, remembering that physiological needs come first. Using this principle, eliminate options 2 and C. Use knowledge regarding sickle cell anemia to direct you to the physiological priority of fluid volume deficit. Review sickle cell anemia if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Planning
Content Area: Maternity/Antepartum
Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 525.

Source : NCLEX example quiz and answer

Read also:

• Example Nursing Register (RN) Questions with Answer and Rationale 59th Edition
• Example Register Nurse (RN) Questions with Answer 58th Edition
• NCLEX PN Quiz with Answer 2019 / 2020 57th Edition

Thank you for your attention with reading our article NCLEX RN Examination (Example and Answer) 60th Edition (Maternity / Antepartum Questions). Thanks for your participation, like and share if this is usefull.

Share this post