Chapter 06 NCLEX RN Review

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12/6/2011Maternal-Newborn Nursing

Chapter 06: NCLEX RN Review Practice Test

You got 17 out of 30 questions correct

1. The client has come to the clinic for her first prenatal visit and tellsthe nurse that she eats only vegetables. To assess for a problem related to this information, the nurse should assess what part of the CBC?

You answered correctly: Hemoglobin

Rationale: The client who is not eating meat may have a problem with decreased iron intake which could impact her hemoglobin level. Polymorphonuclear cells, lymphocytes, and platelets are unrelated to iron intake.Cognitive Level: ApplicationClient Need: Physiological Integrity: Reduction of Risk PotentialIntegrated Process: Nursing Process: AssessmentContent Area: Maternal-NewbornStrategy: Recall that iron deficiency anemia is a risk for vegetarians. Eliminate options 2, 3, and 4 because polymorphonuclear cells, lymphocytes, and platelet

s are unrelated to iron intake.References: Olds, S., London, M., Ladewig, P., & Davidson, M. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, N. J.: Pearson Education, Inc. p. 447-448.Kee, J. L. (2005). Laboratory and diagnostic tests with nursing implications (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., pp. 718-719.

2. The pregnant client has been diagnosed with toxoplasmosis. The nurse realizes that this infection places the fetus at risk for which of the following? Select all that apply.

You answered incorrectly: Central nervous system damage; Microcephaly and hydrocephalus; Raised, red skin rash

The correct answers were: Central nervous system damage; Microcephaly and hydrocephalus

Rationale: Toxoplasmosis can result in fetal convulsions, coma, microcephaly, and hydrocephalus.Cognitive Level: ApplicationClient Need: Physiological Integrity: Physiological AdaptationIntegrated Process: Nursing Process: AnalysisContent Area: Maternal-NewbornStrategy: Knowledge of the complications of toxoplasmosis is essential to answerthe question correctly.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pe

arson Education, Inc., p. 514-515.

3. Which of the following would indicate to the nurse a need for client teaching about avoiding infection with the rubella virus?

You answered incorrectly: Rubella titer 1:10The correct answer was: Rubella titer 1:8

Rationale: Rubella titer of >1:10 is indicative of immunity to rubella. Rubellais a mild illness and the client may or may not be aware of past infection. A r


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ubella titer of 1:8 or less does not demonstrate immunity and avoidance of thosewith rubella infection is indicated.Cognitive Level: AnalysisClient Need: Health Promotion and MaintenanceIntegrated Process: Teaching/LearningContent Area: Maternal-NewbornStrategy: Knowledge of the required titer level that indicates immunity is necessary to answer this question.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., p. 337, 515-516.

4. Which of the following, if revealed in a prenatal interview, would indicate to the nurse that the client has an increased risk for exposure to cytomegalovirus?

You answered incorrectly: Caring for a cat and litter boxThe correct answer was: Working at a day care center

Rationale: Day care workers are frequently exposed to the virus. Exposure to catlitter can result in toxoplasmosis exposure. IV drug use increases the risk forHIV or hepatitis. Giving blood does not increase the client's risk.Cognitive Level: AnalysisClient Need: Physiological Integrity: Physiological Adaptation

Integrated Process: Nursing Process: AssessmentContent Area: Maternal-NewbornStrategy: Knowledge of cytomegalovirus and how it is transmitted will help to answer this question.Reference: Olds, S., London, M., Ladewig, P., & Davidson, M. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, N. J.: Pearson Education, Inc. p. 516-517.

5. Which of the following, if found during prenatal care, would indicate aneed for delivery by Cesarean section?

You answered incorrectly: Positive herpes culture at the first prenatal visit; client asymptomatic at the time of delivery

The correct answer was: History of genital herpes lesions; prodromal symptoms present but no lesions at the time of delivery

Rationale: Indications for Cesarean section are presence of a herpes lesion or prodromal symptoms. If there are no herpes symptoms or lesions, a vaginal delivery is recommended.Cognitive Level: AnalysisClient Need: Physiological Integrity: Reduction of Risk PotentialIntegrated Process: Nursing Process: AssessmentContent Area: Maternal-NewbornStrategy: Knowledge of the risks of herpes lesions transmitted at the time of delivery will aid in answering the question.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Mate

rnal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., p. 517-518.

6. The nurse explains to a pregnant client who is diagnosed with a sexuallytransmitted disease that follow-up includes which of the following?

You answered correctly: Contacting and treating all sexual partners

Rationale: All partners have been exposed and should be made aware, tested, andtreated as indicated. Cesarean section would be appropriate only if there were s


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ymptoms of a herpes lesion or prodromal symptoms. Genetic assessment and more than routine assessment of hematocrit and hemoglobin are not indicated.Cognitive Level: ApplicationClient Need: Health Promotion and MaintenanceIntegrated Process: Nursing Process: ImplementationContent Area: Maternal-NewbornStrategy: Recall that diagnostic screening and referral for treatment are neededfor all partners exposed to a sexually transmitted infection. Eliminate option2 because Cesarean section would be appropriate only if there were symptoms of aherpes lesion or prodromal symptoms. Eliminate options 3 and 4 because geneticassessment and more than routine assessment of hematocrit and hemoglobin are notindicated.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., p. 112.

7. The nurse should plan for Group B streptococcus screening if the pregnant client meets which of the following criteria?

You answered correctly: 36-37 weeks gestation

Rationale: Carrier status of Group B Streptococcus is variable, so identification several weeks before delivery may not identify a woman who is positive at thetime of delivery. The current recommendation is screening during the 36-37th wee

k of gestation. Rash and history of STI do not alter this recommendation.Cognitive Level: ApplicationClient Need: Physiological Integrity: Physiological AdaptationIntegrated Process: Nursing Process: PlanningContent Area: Maternal-NewbornStrategy: Recall that Group B streptococcus screening is time sensitive; the greatest risk to the fetus is at the time of delivery. Eliminate options 1, 3, and4 because rash, time of initial prenatal visit and history of STI do not alterthe recommendation for screening at 36 to 37 weeks gestation.Reference: Olds, S., London, M., Ladewig, P., & Davidson, M. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, N. J.: Pearson Education, Inc. p. 518-519.

8. Which of the following, if revealed prior to collection of a gonorrhea culture, would result in postponing specimen collection? The client:

You answered incorrectly: Reports douching 3 days ago.The correct answer was: Is currently menstruating.

Rationale: Menstrual blood can affect the results of a gonorrheal culture. Otherfactors listed here would not affect the results. However, douching within 24 hours can affect results.Cognitive Level: ApplicationClient Need: Physiological Integrity: Reduction of Risk PotentialIntegrated Process: Nursing Process: AssessmentContent Area: Maternal-Newborn

Strategy: Recall that results of a gonorrhea culture can be affected by menstrual blood. Eliminate options 1, 3, and 4 because other factors identified would not affect the results of the gonorrhea culture. However, douching within 24 hourscan affect results.Reference: Olds, S., London, M., Ladewig, P., & Davidson, M. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, N. J.: Pearson Education, Inc. p. 114.

9. The client has come to the prenatal clinic complaining of repeated nausea and vomiting. The nurse would assess which of the following items that would p


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rovide information regarding client hydration status?

You answered correctly: Urine specific gravity

Rationale: Urine specific gravity is a measure of the concentration of particlesin the urine. Urine specific gravity rises when the client is dehydrated. The other answers are not related to hydration status.Cognitive Level: AnalysisNursing Process: AssessmentClient Need: Physiological Integrity: Reduction of Risk PotentialIntegrated Process: Nursing Process, AssessmentContent Area: Maternal-NewbornStrategy: Knowledge of tests to determine hydration status will be necessary todetermine the correct answer to the question.References: Olds, S., London, M., Ladewig, P., & Davidson, M. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, N. J.: Pearson Education, Inc. p. 787.Kee, J. L. (2005). Laboratory and diagnostic tests with nursing implications (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., p. 433.

10. During a routine prenatal visit, the presence of ketones is noted duringa dipstick analysis of the client's urine. This finding would indicate to the nurse the possibility of what complication of pregnancy?

You answered correctly: Diabetes

Rationale: Normally, ketones are not found in the urine. Presence of ketones mayindicate diabetes and hyperglycemia with fatty acid catabolism. The other answers are unrelated to the presence of ketones in the urine.Cognitive Level: AnalysisClient Need: PHYSIntegrated Process: Nursing Process, DiagnosisContent Area: Diagnostic TestsStrategy: Recall that the presence of ketones may indicate diabetes and hyperglycemia with fatty acid catabolism. Eliminate options 2, 3, and 4 because urine ketones are not associated with these conditions.References: Olds, S., London, M., Ladewig, P., & Davidson, M. (2004). Maternal-N

ewborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, N. J.: Pearson Education, Inc. p. 437-438.Kee, J. L. (2005). Laboratory and diagnostic tests with nursing implications (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., p. 434.

11. The client has completed a three-hour oral glucose tolerance test. The nurse interprets that which of the following results would require follow-up forgestational diabetes?

You answered correctly: 1-hour level of 210 mg/dL

Rationale: A 3-hour oral glucose tolerance test involves assessment of glucose levels prior to ingestion of glucose followed by 3 assessments at 1-hour interval

s after ingestion of 100 gm of oral glucose. Abnormal results include a fastinglevel greater than 105 mg/dL and a 1-hour level greater than 190 mg/dL. Urine glucose and assessment of 6-hour glucose levels are not part of this test.Cognitive Level: AnalysisClient Need: Physiological Integrity: Reduction of Risk PotentialIntegrated Process: Nursing Process: EvaluationContent Area: Maternal-NewbornStrategy: Recall that abnormal results include a fasting level greater than 105mg/dL and a 1-hour level greater than 190 mg/dL. Eliminate option 1 because it contains normal assessment findings. Eliminate options 3 and 4 because urine gluc


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ose and assessment of 6-hour glucose levels are not part of this test.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., p. 440.

12. A pregnant client has come to the clinic for a triple screen test. Whichof the following statements by the client indicate the nurse's teaching about the test has been effective? Select all that apply.

You answered incorrectly: "I kept my 24-hour urine sample refrigerated and brought it with me today."; "I am having this test to determine if my baby has Down syndrome."; "When will I know my blood levels of serum alpha-fetoprotein, estriol, and hCG?"The correct answers were: "When will I know my blood levels of serum alpha-fetoprotein, estriol, and hCG?"; "I am having this test to determine if my baby has Down syndrome."

Rationale: The triple screen test determines serum levels of serum alpha-fetoprotein, estriol, and human chorionic gonadotropin (hCG), markers for neural tube defects and trisomies 18 and 21 (Down syndrome.) Maternal serum, not urine, is assessed in this test. A 3-day high carbohydrate diet would be recommended priorto a 3-hour glucose tolerance test.Cognitive Level: AnalysisClient Need: Physiological Integrity: Reduction of Risk Potential

Integrated Process: Teaching/LearningContent Area: Maternal-NewbornStrategy: Recall that the triple screen test relies on evaluation of 3 serum markers to screen for neural tube defects and chromosomal trisomies. Eliminate options 1, 3, and 4 because urine, diet alterations and sound waves are not part ofthis test.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., p. 349.

13. The client is a 37-year-old gravida one at 38 weeks gestation. She was diagnosed with diabetes at age 17 and is scheduled for an amniocentesis. The nurse interprets that the procedure is probably being done to assess for the presenc

e of:

You answered incorrectly: Neural tube defects.The correct answer was: Lung maturity.

Rationale: Amniocentesis done for genetic testing is usually done early in the second trimester. This test, being done on a client who has diabetes and is at 38weeks gestation, is probably being done to assess lung maturity in anticipationof delivery.Cognitive Level: AnalysisClient Need: Physiological Integrity: Physiological AdaptationIntegrated Process: Nursing Process: AnalysisContent Area: Maternal-Newborn

Strategy: This question is time sensitive. Recall that amniocentesis done late in pregnancy is used to assess fetal lung maturity. Eliminate options 1 and 2 because testing for genetic disorders is performed in the second trimester. Eliminate option 3 because amniocentesis is not used to assess TORCH infections.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., p. 547, 553.

14. A client has been scheduled for an amniocentesis. Nursing interventionsshould include which of the following?


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You answered correctly: Arrange for access to an ultrasound machine for use during the procedure.

Rationale: The test, completed on an outpatient basis, is done under guidance ofultrasound visualization. The test is done without anesthetic or with a local anesthetic. The client is positioned on her back with a wedge under her left hipto avoid hypotension from pressure of the uterus on the vena cava.Cognitive Level: ApplicationClient Need: Physiological Integrity: Reduction of Risk PotentialIntegrated Process: Nursing Process: PlanningContent Area: Maternal-NewbornStrategy: Eliminate options 1 and 4 because amniocentesis is an outpatient procedure performed with the client awake. Eliminate option 3 because a supine position is avoided to reduce the risk of vena cava syndrome.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., pp. 547-550.

15. The client is scheduled to have an amniocentesis for assessment of lungmaturity. She seems upset and says that she doesn't understand how this test could tell if a baby's lungs are mature. The nurse's best response is:

You answered correctly: "A chemical called lecithin is made by the fetal lungs.

The amount of it increases as gestation continues. It flows out into the amniotic fluid where we can measure it to determine lung maturity."

Rationale: The amount of lecithin increases as the fetal lungs mature. The ratioof lecithin to sphingomyelin is used to assess lung maturity. The other answersare incorrect.Cognitive Level: ApplicationClient Need: Physiological Integrity: Reduction of Risk PotentialIntegrated Process: Communication and DocumentationContent Area: Maternal-NewbornStrategy: Knowledge of the procedure and what it is used for will aid in choosing the correct answer.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Mate

rnal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., p. 547, 553.

16. The nurse would choose which of the following as an appropriate nursingdiagnosis for a client about to undergo an amniocentesis?

You answered correctly: Anxiety related to concern for fetal well-being

Rationale: Most women view invasive antenatal testing with anxiety because of the reason for the test, the impending results, and concern about maternal and fetus complications. The other diagnosis are not necessarily related to undergoingan amniocentesis.Cognitive Level: Analysis

Client Need: Psychosocial IntegrityIntegrated Process: Nursing Process: DiagnosisContent Area: Maternal-NewbornStrategy: Recall that an amniocentesis is an invasive test commonly accompaniedby client anxiety related to the procedure or the findings. Eliminate option 1 because the client does not need to be NPO for the procedure. Eliminate option 2because only local anesthesia is used. Eliminate option 4 because only a small amount of amniotic fluid is removed for assessment.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pe


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arson Education, Inc., p. 550.

17. The nurse would report which of the following assessment findings in a pregnant client as a contraindication for conducting a contraction stress test?

You answered correctly: Marginal abruptio placentae

Rationale: Contractions elicited during the test could cause increased bleedingif an abruption is present. Intrauterine growth restriction, diabetes mellitus,and post term pregnancy are all indications for completing a contraction stresstest.Cognitive Level: AnalysisClient Need: Physiological Integrity: Reduction of Risk PotentialIntegrated Process: Communication and DocumentationContent Area: Maternal-NewbornStrategy: The core issue of the question is determining when contractions wouldpresent an increased risk to client or fetal safety. Recall that contractions could increase placental abruption and bleeding. Eliminate options 1, 2, and 3 because intrauterine growth restriction, diabetes mellitus, and post term pregnancyare all indications for completing a contraction stress test.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., p. 538.

18. The nurse notes that which of the following findings on a biophysical profile would result in a decrease in the score?

You answered correctly: 1 episode of body movement in a 30-minute time period

Rationale: Normal findings would include 3 or more discrete body/limb movementsin 30 minutes; this abnormal finding would result in a score of 0 for this criterion of the test. Findings in options 2, 3, and 4 are normal findings and wouldreceive scores of 2 respectively.Cognitive Level: AnalysisClient Need: Physiological Integrity: Reduction of Risk PotentialIntegrated Process: Nursing Process: EvaluationContent Area: Maternal-Newborn

Strategy: Recall that decreased fetal movement is an abnormal finding on a biophysical profile. Eliminate options 2, 3, and 4 because they are normal findings and would receive scores of 2 respectively.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., pp. 541-542.

19. In taking a history from a pregnant client, the nurse would recognize which of the following as a risk factor for contraction of sexually transmitted disease?

You answered incorrectly: Use of oral contraceptivesThe correct answer was: Report of anal intercourse

Rationale: Because it frequently involves tissue trauma that facilitates invasion of pathogens, anal intercourse is considered a high-risk sexual behavior. Theother factors listed here do not increase the client's risk for contractions ofa sexually transmitted infection.Cognitive Level: AnalysisClient Need: Physiological Integrity: Physiological AdaptationIntegrated Process: Nursing Process: AssessmentContent Area: Maternal-NewbornStrategy: Recall that anal intercourse increases the risk of tissue trauma and p


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athogen invasion. Eliminate options 2, 3, and 4 because these factors do not increase the client's risk for acquiring a sexually transmitted infection.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., p. 112.

20. In interviewing a pregnant client concerning sexually transmitted infections, the nurse should recognize which of the following as a barrier to client disclosure?

You answered correctly: Use of only yes or no questions

Rationale: Use of open-ended questions, framed in a culturally sensitive and nonjudgmental approach, tends to establish a trusting and open relationship for information exchange. Asking only questions with a yes and no response do no elicitinformation but may close the conversation.Cognitive Level: ApplicationClient Need: Psychosocial IntegrityIntegrated Process: Communication and DocumentationContent Area: Maternal-NewbornStrategy: Key words are "barrier to client disclosure." This indicates that youare looking for an answer that will discourage the client from elaborating. Thusthe yes and no answers to questions would be the correct response.Reference: Olds, S., London, M., Ladewig, P., & Davidson, M. (2004). Maternal-Ne

wborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, N. J.: Pearson Education, Inc. p. 118.

21. A female client seeks medical care after noticing multiple soft, grayish-pink, cauliflower-like lesions in her genital area. The nurse anticipates thatthe client should have diagnostic testing for which of the following sexually transmitted infections?

You answered correctly: Human papilloma virus

Rationale: The client's symptoms suggest an infection of human papilloma virus on her vulva. A biopsy is needed for a definitive diagnosis.Cognitive Level: Analysis

Client Need: Physiological Integrity: Reduction of Risk PotentialIntegrated Process: Nursing Process: PlanningContent Area: Maternal-NewbornStrategy: Knowledge of the diagnostic tests used to determine human papilloma virus will be necessary to choose the correct answer.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., p. 115.

22. The nurse expects that which of the following specimens will be obtainedto provide a noninvasive, reliable screen for cocaine use in the pregnant client?

You answered correctly: Urine

Rationale: Cocaine metabolites may be present in the urine of a pregnant woman for 4-7 days following use. The other choices are inappropriate and do not meet the criterion of being noninvasive.Cognitive Level: AnalysisClient Need: Physiological Integrity: Reduction of Risk PotentialIntegrated Process: Nursing Process: AssessmentContent Area: Maternal-NewbornStrategy: The critical word in the question is noninvasive. Eliminate options 2,


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3, and 4 as they require invasive testing.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., p. 385.

23. The nurse explains to a pregnant client that maternal screening for Group B streptococcus is important because the microorganism can result in:

You answered correctly: Neonatal sepsis.

Rationale: Group B streptococcus, considered normal vaginal flora for many women, is usually transmitted to the fetus during labor and delivery and can result in neonatal sepsis. The other answers do not provide correct information about diseases that can result from this organism.Cognitive Level: ApplicationClient Need: Physiological Integrity: Reduction of Risk PotentialIntegrated Process: Teaching/LearningContent Area: Maternal-NewbornStrategy: Recall that the Group B streptococcus is a bacteria with risk for infection in the fetus. Eliminate options 1 and 3 because this organism does not cause these maternal infections. Eliminate option 4 because it does not focus on aninfectious process.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: P

earson Education, Inc., p. 518.

24. The pregnant client, a cat owner, has called the office complaining of flu-like symptoms. The nurse suspects that the client might have contracted toxoplasmosis. Which of the following would best be used as a diagnostic tool when the client is asked to come into the office to be seen?

You answered correctly: Indirect florescent antibody test

Rationale: Toxoplasmosis can be diagnosed by indirect florescent antibody test.If a culture were desired, it would be obtained from blood, however, cultures oftoxoplasmosis are difficult to obtain. The VDRL is a test for syphilis. Urine toxicology is used to screen for drug use.

Cognitive Level: ApplicationClient Need: Physiological Integrity: Reduction of Risk PotentialIntegrated Process: Nursing Process: PlanningContent Area: Maternal-NewbornStrategy: The core issue of the question is a diagnostic test for toxoplasmosis.Eliminate option 4 because a cervical culture would not be specific for this disease. Eliminate option 3 because the VDRL is a test for syphilis. Eliminate option 1 because urine toxicology is used to screen for drug use.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., pp. 514-515.

25. A client has come to the clinic for her first prenatal visit. In talking

with her, the nurse discovers that the client frequently eats undercooked meat.A priority nursing diagnosis for the client would be:

You answered correctly: Risk for ineffective heath maintenance related to lack of knowledge about ways in which a pregnant woman can contract toxoplasmosis.

Rationale: Toxoplasmosis can be contracted by eating undercooked and infected meat. Meat consumption would increase iron intake. There is no indication that sheis consuming too many calories or that other family members will need to changetheir eating habits.


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Cognitive Level: AnalysisClient Need: Health Promotion and MaintenanceIntegrated Process: Nursing Process: AnalysisContent Area: Maternal-NewbornStrategy: The focus of the question is client risk from eating undercooked meat,toxoplasmosis. Eliminate option 2 because meat consumption would increase ironintake. Eliminate options 1 and 4 because there is no indication that the clientis consuming too many calories or that other family members will need to changetheir eating habits.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., pp. 514-515.

26. The nurse has just completed teaching a client who is to have a maternalserum alpha-fetoprotein screening. Which of the following statements by the client would indicate a need for further teaching? Select all that apply.

You answered incorrectly: "I understand that if this test is normal I won't haveto worry about having a baby with a birth defect."; "I understand that this test will be done on amniotic fluid."The correct answers were: "I understand that if this test is normal I won't haveto worry about having a baby with a birth defect."; "I understand that this test will let us know if my baby has Down Syndrome."; "I understand that this testwill be done on amniotic fluid."

Rationale: Maternal serum alpha-fetoprotein is a screening test not a diagnostictest that uses a maternal blood test, and does not rule out or prove that an infant has a neural tube defect. There are false positive results. If elevated, itis an indicator that further testing is warranted to establish a diagnosis.Cognitive Level: ApplicationClient Need: Physiological Integrity: Reduction of Risk PotentialIntegrated Process: Nursing Process: EvaluationContent Area: Maternal-NewbornStrategy: Knowledge of the use of maternal serum alpha-fetoprotein screening test will aid in choosing the correct answer.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: P

earson Education, Inc., pp. 545-547.

27. The client is 37 weeks pregnant. In reviewing the client's chart, the nurse notes that an amniocentesis was performed to assess fetal lung maturity. Which of the following findings would indicate that the fetus's lungs are mature?

You answered incorrectly: L/S ratio 1:1The correct answer was: Phosphatidylglycerol

Rationale: Phosphatidylglycerol, when present in amniotic fluid, is associated with very low risk for respiratory distress syndrome. An L/S ratio of 2:1 indicates lung maturity. Optical density is used to assess bilirubin concentrations. Human chorionic gonadotrophin is part of the triple screen used to assess for cert

ain birth defects.Cognitive Level: AnalysisClient Need: Physiological Integrity: Physiological AdaptationIntegrated Process: Nursing Process: AssessmentContent Area: Maternal-NewbornStrategy: The core focus of the question is a normal assessment finding for fetal lung maturity. Eliminate option 2 because it contains a finding of fetal lungimmaturity. Eliminate options 3 and 4 because they are not findings related to lung maturity.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Mat


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ernal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., pp. 552-553.

28. The nurse is assessing the fetal heart monitor strip of a client havinga contraction stress test. Which of the following, if noted by the nurse, wouldindicate a negative test?

You answered incorrectly: Late decelerations after one contraction on a strip with three contractions within a 10-minute time frame.The correct answer was: No late decelerations after any contractions on a stripwith three contractions within a 10-minute time frame.

Rationale: The contraction stress test is an assessment of the respiratory function of the placenta. A negative test indicates that uteroplacental function is adequate to allow the fetus to withstand the stress of labor at this time.Cognitive Level: AnalysisClient Need: PHYSIntegrated Process: Nursing Process, EvaluationContent Area: Diagnostic TestsStrategy: Knowledge of the contraction stress test and the interpretation of theresults will aid in choosing the correct answer. Recall that a negative test has no late decelerations. Eliminate options 2 and 3 because late decelerations are present. Eliminate option 4 because accelerations are described.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Mat

ernal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., p. 538, 540-541.

29. The client, who is to have transcervical chorionic villus sampling (CVS), has completed her teaching session concerning the test and its potential complications. Which of the following statements by the client to the nurse would indicate understanding of the information?

You answered incorrectly: "This test will be done when I am between 16 and 18 weeks pregnant."The correct answer was: "In very rare cases, this test can cause fetal limb reduction defects."

Rationale: Chorionic villus sampling, usually completed between 10 and 12 weeksgestation, can rarely result in loss of a portion of the fetus's finger or toe.Transcervical sampling is done with the use of a catheter that is inserted through the endocervix not through the abdomen.Cognitive Level: ApplicationClient Need: Physiological Integrity: Reduction of Risk PotentialIntegrated Process: Nursing Process: EvaluationContent Area: Maternal-NewbornStrategy: Knowledge of the use of CVS and the procedure will enable the selection of the correct answer.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., pp. 550-551.

30. A client, who is 28 weeks pregnant, has had an abnormal Doppler blood flow assessment. The nurse interprets that the client will need to be carefully monitored for which of the following?

You answered incorrectly: Insufficient maternal oxygen levelsThe correct answer was: Inadequate fetal growth

Rationale: An abnormal Doppler blood flow indicates impaired uteroplacental or umbilical blood flow and places the infant at risk for intrauterine growth restri


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ction. The other answers are incorrect.Cognitive Level: ApplicationClient Need: PHYSIntegrated Process; Nursing Process, AssessmentContent Area: Diagnostic TestsStrategy: The core focus of the question is blood flow. The correct answer would be the option that contains a true statement about the risk of uteroplacentalinsufficiency. Eliminate options 1, 3, and 4 because they are not related to uteroplacental blood flow.Reference: Olds, S.B., London, M.L., Ladewig, P.A. & Davidson, M.R. (2004). Maternal-Newborn Nursing & Women's Health Care (7th ed.). Upper Saddle River, NJ: Pearson Education, Inc., pp. 542-543.

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Chapter 06 NCLEX RN Review