1000 NCLEX Question with Answer 124th Edition

1000 NCLEX Question with Answer 124th Edition

1000 NCLEX Question with Answer 124th Edition

1. A nurse understands that becoming familiar with the cultural beliefs and practices of a childbearing woman may facilitate positive outcomes during pregnancy since:

A. All women are comfortable discussing sexual practices with their health care providers
B. Many women exist in traditional relationships with their sexual partners, thus discussing and making decisions about reproductive issues may be difficult for some
C. All males are knowledgeable about issues related to the spread of sexually transmitted diseases
D. Safe sex practices are common among couples 18 years of age and older

Answer: B. Many women exist in traditional relationships with their sexual partners, thus discussing and making decisions about reproductive issues may be difficult for some

Rationale: The nurse providing care for women in their childbearing years must be familiar with the cultural framework within which the client lives and operates. Once this is achieved, appropriate communication techniques can be employed to facilitate client assessment and care and to identify health-promotion educational strategies. Options 1, 3, and 4 identify statements that generalize childbearing clients. Option 2 identifies a basic nursing philosophy that recognizes the importance of understanding the client’s cultural background as the initial step in establishing the nurse-client relationship.

Test-Taking Strategy: Use the process of elimination and knowledge regarding the importance of understanding the cultural beliefs and practices of the client. Avoid stereotypical statements as identified in option D. Eliminate options 1 and 3 because of the absolute word “all.” Review the importance of understanding cultural practices if you had difficulty with this question.

Level of Cognitive Ability: Comprehension
Client Needs: Psychosocial Integrity
Integrated Process: Caring
Content Area: Fundamental Skills
Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 44, 102.

2. A nurse is reviewing the test results for the rubella screening with a pregnant 24-year-old client. The test results are positive, indicating immunity, and the client asks if it is safe for her 15-month-old toddler to receive the vaccine. The best response is:

A. “You are still susceptible to rubella, so your toddler should receive the vaccine.”
B. “Most children do not receive the vaccine until 5 years of age.”
C. “It is not advised for children of pregnant women to be vaccinated during their mother’s pregnancy.”
D. “Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time.”

Answer: D. “Your titer supports your immunity to rubella, and it is safe for your toddler to receive the vaccine at this time.”

Rationale: All pregnant women should be screened during pregnancy for prior rubella exposure. All children of pregnant women (12 to 15 months of age) should receive their immunizations according to schedule since there is no definitive evidence that the vaccine virus is transmitted from person to person. A positive maternal titer further indicates that a significant antibody titer has developed in response to a prior exposure to the Rubivirus, which is traditionally spread by oral droplets and transplacentally.

Test-Taking Strategy: Use the process of elimination and knowledge of rubella disease transmission and pregnancy to direct you to option D. Noting the key words indicating immunity will direct you to option D. Review content related to rubella during pregnancy if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Safe, Effective Care Environment
Integrated Process: Nursing Process/Implementation
Content Area: Maternity/Antepartum
Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 109, 74B.

3. A pregnant client has a positive pulmonary identification of the tuberculosis (TB) organism, and isoniazid (INH) and rifampin (Rifadin) are prescribed. The nurse plans to do which of the following when reinforcing home care instructions?

A. Review daily nutritional intake with the client
B. Encourage the client to stop taking medications during the last trimester of pregnancy
C. Inform the client that follow-up care after delivery will not be necessary
D. Tell the client that newborns and infants are usually not susceptible to tuberculosis infection following delivery and will not need to be tested

Answer: A. Review daily nutritional intake with the client

Rationale: Social conditions placing pregnant women at risk for TB include poverty, crowded living conditions, and malnutrition. In the case of acute disease during the antenatal period, a 9-month course of isoniazid (INH) and rifampin (Rifadin) is suggested. Follow-up sputum screenings and evaluation are essential to establish treatment effectiveness postdelivery. Teaching the client about the importance of an adequate nutritional intake needs to be included in the home care instructions. Options 2, 3, and 4 are incorrect.

Test-Taking Strategy: Use the process of elimination and knowledge regarding the pathophysiology and transmission of TB to answer this question. This will assist in eliminating options 2, 3, and D. Review these home care instructions if you had difficulty with this question.

Level of Cognitive Ability: Application
Client Needs: Physiological Integrity
Integrated Process: Teaching/Learning
Content Area: Maternity/Antepartum
References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 11A.
Murray, S., McKinney, E., & Gorrie, T. (2002). Foundations of maternal-newborn nursing (3rd ed.). Philadelphia: W.B. Saunders, pp. 730-73A.

4. A nurse instructs a pregnant human immunodeficiency virus (HIV)-positive client to report any early signs of vaginal discharge or perineal tenderness to the health care provider immediately. The nurse tells the client that this is important to:

A. Relieve anxiety for the pregnant client
B. Eliminate the need for further unnecessary screenings
C. Assist in identifying potential infections that may need to be treated
D. Minimize the financial cost of caring for an HIV-positive client

Answer: C. Assist in identifying potential infections that may need to be treated

Rationale: The HIV-positive client may be further at risk for superimposed infections during pregnancy. Among these include Candida infections, genital herpes, and anogenital condyloma. Early reporting of symptoms may alert the members of the health care team that further assessment and testing is necessary to diagnose and manage additional maternal and fetal physiological risks. Options 1, 2, and 4 are not the priority of care when promoting maternal-fetal well-being.

Test-Taking Strategy: Use the process of elimination and focus on the issue of the question. Note the relationship between “vaginal discharge or perineal tenderness” in the question and “infections” in the correct option. Review the purpose of health care instructions in the client with HIV if you had difficulty with this question.

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. 340.

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