Assignment 1: NCLEX Question Design

Eugenia Long

NURS 603

Dr. Kirsty Digger

April 5th, 2018

 Content Area: Ante/Intra/Postpartum and Newborn Care

The content area I chose for development of NCLEX questions is Ante/Intra/Postpartum

and Newborn Care. The following are the associated topics covered as per the Nurse Educator

version of the 2016 NCLEX Test Plan (National Council of State Boards of Nursing, 2016):

 Assess client’s psychosocial response to pregnancy (e.g., support systems, perception

of pregnancy, coping mechanisms)

 Assess client for symptoms of postpartum complications (e.g., hemorrhage, infection)

 Recognize cultural differences in childbearing practices „

 Calculate expected delivery date„

 Check fetal heart rate during routine prenatal exams„

 Assist client with performing/learning newborn care (e.g., feeding)

 Provide prenatal care and education*

 Provide care and education to client in labor or an antepartum client„

 Provide post-partum care and education*

 Provide discharge instructions (e.g., post-partum and newborn care)

 Evaluate client’s ability to care for the newborn

In addition to the topical outline above, the NCLEX Test Plan also delineates the following

content categories, which apply to all topics covered by the exam (National Council of State

Boards of Nursing, 2016):

 Safe and effective care environment

o Management of care

o Safety and infection control

 Health promotion and maintenance

  Psychosocial integrity

 Physiological integrity

o Basic care and comfort

o Pharmacological and parenteral therapies

o Reduction of risk potential

o Physiological adaptation

Test Questions

(Note: Questions 1 - 6 are modifications of questions taken from NCLEX-RN Maternal-Neonatal Nursing

Made Incredibly Easy (Meyering, 2011). The original questions are listed in the appendix, along with the

question number they are assigned in the book. Questions 7 – 10 are original.)

1. A client with painless vaginal bleeding at 30 weeks’ gestation has just been diagnosed as having

placenta previa. Which statement by the client indicates that she understands the nurse’s

teaching?

1) “I will still be able to fly to California for the holidays.”

2) “I can continue to go to exercise class three times a week.”

3) “If I experience vaginal bleeding, I should apply a sanitary pad and rest.”

4) “I should avoid sexual intercourse with my husband.”

Bloom’s Taxonomy: This question tests application, because it necessitates the student

demonstrate proper judgment and use preexisting knowledge about placenta previa to determine

appropriate vs. inappropriate patient statements. Application requires that the student “selects,

transfers, and uses data and principles to complete a problem or task with a minimum of direction”

(Huitt, 2011).

Test Blueprint: Provision of prenatal care and education.

 NCLEX Category: Physiological integrity: Reduction of risk potential.

Correct Response: “I should avoid sexual intercourse with my husband.” The patient with

placenta previa should avoid intercourse as a bleeding precaution. There is concern that vaginal

intercourse may cause bleeding via direct trauma to the previa (Lockwood & Russo-Stieglitz,

2018).

Incorrect Responses: Responses 1, 2, and 3 are incorrect because patients with placenta previa

should restrict activities and avoid long-distance travel, sexual intercourse, and strenuous activity

(Meyering, 2011).

2. Which intervention should the nurse implement in the client scheduled for amniocentesis?

1) Tell the client to drink 2L of water.

2) Have the client void prior to the procedure.

3) Instruct the client to fast for 8 hours.

4) Place the client on her left side.

Bloom’s Taxonomy: This question tests application, because the student needs to demonstrate

knowledge of the amniocentesis procedure and physiology of pregnancy in order to answer

correctly. Demonstration and application of knowledge falls under this level of taxonomy (Huitt,

2011).

Test Blueprint: Provide prenatal care and education.

NCLEX Category: Safe and effective care environment: Management of care; Physiological

integrity: reduction of risk potential.

 Correct Response: Having the client void reduces the risk of bladder perforation during the

procedure (Meyering, 2011).

Incorrect Responses: The patient does not need to drink water or fast prior to the procedure, and

should be supine (Meyering, 2011).

3. Accompanied by her father, a primiparous 16-year-old client arrives for her first prenatal visit at

29 weeks’ gestation. Her father refuses to leave the room, stating that the girl is shy and he will

answer the questions for her. Which aspect of this situation should be of most concern to the

nurse?

1) The possibility of preterm labor with an adolescent pregnancy

2) Unknown HIV status due to late initiation of prenatal care

3) Possible child abuse or domestic violence

4) Behavioral and educational challenges of the gravid teenage client

Bloom’s Taxonomy: This question tests analysis, because the student must classify the concerns

presented and analyze the situation for the priority concern. Skills such as analysis, classification,

comparison, categorization and relation of assumptions fall under the analysis taxonomy (Huitt,

2011).

Test Blueprint: Assess client’s psychosocial response to pregnancy, provide prenatal care.

NCLEX Category: Psychosocial integrity.

Correct Response: The possibility of abuse is the priority concern in this situation, and the

father’s refusal to leave the room as well as the late gestational age upon presentation are

suspicious. Abuse victims will typically remain silent if their abuser is present, so the nurse

should attempt to speak with the patient alone and possibly involve social work (Meyering, 2011).
 Incorrect Responses: None of the other options are urgent issues; they are potential issues, but

are not immediate threats to patient safety. All incorrect responses are appropriate concerns, but

the possibility of abuse is the priority concern (Meyering, 2011).

4. During the second and third trimesters, common pregnancy discomforts may increase in severity.

Which discomforts would the nurse normally expect to see?

1) Ankle edema, Braxton Hicks contractions, and nausea and vomiting

2) Braxton Hicks contractions, shortness of breath, and increased vaginal discharge

3) Leg cramps, light vaginal spotting, and nausea and vomiting

4) Leg cramps, ankle edema, and shortness of breath

Bloom’s Taxonomy: this question tests the student at the application level. The student must

apply their knowledge of the physiological changes experienced in each trimester to manifested

symptoms. The student must then separate the appropriate from inappropriate physiological

symptoms for this gestational period.

Test Blueprint: Provide prenatal care and education.

NCLEX Category: Health promotion and maintenance; Physiological integrity: physiological

adaptation.

Correct Response: Leg cramps, ankle edema, and shortness of breath are all normal physiological

symptoms experienced during the second and third trimester of pregnancy (Meyering, 2011).

Incorrect Responses: Options 1 and 2 include nausea and vomiting and increased vaginal

discharge, respectively; both of these symptoms are expected in the first trimester and should now

be subsiding (Meyering, 2011). Option 3 includes nausea and vomiting as well as vaginal
 spotting, which should be investigated to rule out placenta previa, placental abruption, preterm

labor, or cervical inflammation (Mayo Clinic, 2018).

5. Immediately after delivery, a nurse assesses the neonate’s respiratory effort as depressed. The

neonate is actively moving but grimaces in response to stimulation. His fingers and toes are

bluish, and his heart rate is 120 beats per minute. Which step should the nurse take next?

1) Tell the physician that the neonate appears normal

2) Assign an Apgar score of 8

3) Provide positive pressure ventilation with supplemental oxygen

4) Stimulate the baby to cry

Bloom’s Taxonomy: This question tests the student at the analysis level. The student must

analyze the neonate’s vital signs, appearance and behavior, and use the available evidence to

distinguish the most appropriate course of action.

Test Blueprint: Provide postpartum care (in this instance, to the newborn)

NCLEX Category: Physiological integrity: physiological adaptation, pharmacological therapies

(oxygen); Safe and effective care environment.

Correct Response: This infant needs to be stimulated to cry. The nurse should vigorously dry

the infant in order to do this (American Heart Association, 2015).

Incorrect Responses: The infant’s Apgar score is 7, not 8, due to its grimace in response to

stimulation, depressed respirations, and acrocyanosis (ACOG, 2015). The infant does not appear

normal due to the findings of grimacing in response to stimulation and depressed respirations.

Supplemental oxygen and positive-pressure ventilation are inappropriate at this time; the nurse
 should first attempt to stimulate the infant to cry per the neonatal resuscitation algorithm

(American Heart Association, 2015).

6. A 30-year-old female client has her first prenatal visit at 16 weeks’ gestation. Which finding

during this visit is abnormal?

1) Fundal height of 20cm

2) Blood pressure of 128/76mmHg

3) Urine negative for protein

4) Weight of 134lbs (60.9kg)

Bloom’s Taxonomy: This question tests the student at the application level due to the components

of analyzing the patient’s clinical situation, categorizing findings as normal or abnormal, and

comparing/contrasting the options with norms for the patient presented. Analysis, categorization,

comparison and contrast fall under the analysis level of taxonomy (Huitt, 2011).

Test Blueprint: Calculate expected delivery date, provide prenatal care

NCLEX Category: Physiological integrity: physiological adaptation, reduction of risk potential

Correct Response: A fundal height of 20cm is higher than expected for a gestational age of 16

weeks, whose fundal height should be approximately 16cm (Meyering, 2011).

Incorrect Responses: The patient’s weight, blood pressure, and lack of proteinuria are normal

(Meyering, 2011).

7. A nurse is administering intramuscular oxytocin (Pitocin) to a postpartum patient in the fourth

stage of labor. The medication is supplied in a concentration of 50 units/5mL, and the dose
 ordered is 20 units. How many milliliters should the nurse administer? Record your answer using

up to two decimal points as appropriate.

_________2______mL

Bloom’s Taxonomy: The need to compute or solve for the answer places this question at the

application level of Bloom’s taxonomy (Huitt, 2011). Here the student must apply the correct

dosage calculation equation to compute the correct amount of medication to administer.

Test Blueprint: Provide postpartum care and education

NCLEX Category: Safe and effective care environment; Physiological integrity: pharmacological

and parenteral therapies.

Correct Response: 2mL. Using the D/H x Q equation, in which D represents the dose ordered, H

represents the dose on hand, and Q represents the quantity, we use the following steps:

1) D/H x Q

2) 20/50 x 5

3) 0.4 x 5

4) 2

5)

8. A nurse is administering Vitamin K (Phytonadione) to a newborn infant. Indicate on the below

diagram the best administration site for this medication.

Bloom’s Taxonomy: This question tests the student at the application level. The student must apply

the knowledge that Vitamin K is an intramuscular injection, and select the appropriate muscle for this

medication in the neonate. This question builds on comprehension of neonatal injection site selection

for intramuscular medications.

Test Blueprint: Provide postpartum care (to neonate).

NCLEX Category: Safe and effective care; Physiological integrity: pharmacological and parenteral

therapies, reduction of risk potential.

Correct Response: The student should indicate the brown area on the diagram, which illustrates the

vastus lateralis muscle:

9. The nurse is monitoring a 19-year-old intrapartum patient in active labor. The patient has a

continuous epidural infusion in place and moderate amounts of green amniotic fluid, and is

receiving intravenous oxytocin at a rate of 6mU/min. She is contracting every 1.5 minutes for 60-

90 seconds per contraction. She is comfortable in a supine position. The nurse observes recurrent

late decelerations on the fetal monitoring strip. Place the following nursing interventions in the

order in which they should be performed.

a) Administer oxygen via nonrebreather mask at 10L/min.

b) Notify provider.

c) Initiate amnioinfusion.

d) Reposition patient on her left side.

e) Discontinue oxytocin infusion.

 Bloom’s Taxonomy: This question tests students at the synthesis level, because the student must

integrate and combine concepts into a plan (Huitt, 2011). The student must take understanding of

the interventions and develop a strategy to provide optimal patient care.

Test Blueprint: Provide care to the client in labor.

NCLEX Category: Safe and effective care environment: management of care; Physiological

integrity: Pharmacological therapies, reduction of risk potential.

Correct Response: E. The patient’s uterine contractions surpass the safe rate of five or fewer per

ten minutes (Miller, Miller, & Tucker, 2013).

D. Supine positioning decreases fetal oxygenation by putting pressure on the

inferior vena cava, thus decreasing intervillous filling (Miller et al, 2013).

A. Data supports this level of oxygen administration to increase fetal hemoglobin

saturation (Miller et al, 2013).

B. The provider needs to be notified before amnioinfusion can be given, since the

nurse will need intrauterine access and an order for this intervention; the three prior

intrauterine resuscitation interventions can be carried out independently at the bedside.

C. Amnioinfusion would be given only with a provider’s order after evaluation.

10. Which statements from a postpartum patient indicate correct understanding of patient teaching?

(Select all that apply.)

a) “I should expect vaginal bleeding for up to six weeks following my delivery.”

b) “I should call my doctor if I experience foul-smelling vaginal discharge.”

 c) “I should wear a supportive bra for my comfort.”

d) “I can apply cold compresses prior to breastfeeding to prevent nipple soreness.”

e) “I should contact my doctor if I feel depressed for more than six weeks following

delivery.”

f) “I should avoid sex and tampons until my doctor sees me for follow-up.”

Bloom’s Taxonomy: This question tests students at the application level. The student must apply his

or her understanding of normal postpartum changes to these sample patient statements, and parse the

correct vs. incorrect statements.

Test Blueprint: Provide postpartum care and education; provide discharge instructions.\

NCLEX Category: Health promotion and maintenance; psychosocial integrity; physiological

integrity: reduction of risk potential, physiological adaptation.

Correct Response: Per Meyering (2011), options B, C, and F demonstrate appropriate understanding

of normal postpartum changes and discharge teaching.

Incorrect Responses: A indicates a knowledge gap because the patient should expect vaginal

bleeding to lighten after the first few days, with lochia alba persisting for up to six weeks (Meyering,

2011). D demonstrates an incorrect understanding of the use of cold; only warm compresses should

be used prior to feedings, and cold compresses are used for engorgement, not to relieve soreness

(Meyering, 2011). E demonstrates an incorrect understanding because the patient should contact her

provider after two weeks of depressive symptoms, not six (Meyering, 2011).
 References

American College of Obstetricians and Gynecologists. (2015). Committee opinion: The Apgar score.

ACOG. Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Committee-

Opinions/Committee-on-Obstetric-Practice/The-Apgar-Score

American Heart Association. (2015). Neonatal resuscitation algorithm- 2015 update. American Heart

Association. Retrieved from http://eccguidelines.heart.org/wp-content/uploads/2015/10/Neonatal-

Resuscitation-Algorithm.pdf

Huitt, W. (2011). Bloom et al.'s taxonomy of the cognitive domain. Educational Psychology Interactive.

Retrieved from http://www.edpsycinteractive.org/topics/cogsys/bloom.html

Lockwood, C. J., & Russo-Stieglitz, K. (2018). Placenta previa: Management. UpToDate. Retrieved

from https://www.uptodate.com/contents/placenta-previa-management

Mayo Clinic. (2018). Symptoms: Bleeding during pregnancy. Mayo Clinic. Retrieved from

https://www.mayoclinic.org/symptoms/bleeding-during-pregnancy/basics/causes/sym-20050636

Meyering, J. (Ed.). (2011). NCLEX-RN maternal-neonatal nursing made incredibly easy. Ambler, PA:

Lippincott Williams & Wilkins.

Miller, L. A., Miller, D. A., & Tucker, S. M. (2013). Mosby’s pocket guide to fetal monitoring: A

multidisciplinary approach. St. Louis, MO: Elsevier, Inc.

National Council of State Boards of Nursing. (2016). NCLEX-RN examination: Detailed test plan for

the National Council licensure examination for registered nurses. National Council of State Boards of

Nursing. Retrieved from https://www.ncsbn.org/2016_RN_DetTestPlan_Educator.pdf

 Appendix: Original Questions for Items 1 - 6

6. Which intervention should the nurse implement in the client scheduled for amniocentesis?

1. Tell the client to drink 1L of water.

2. Have the client void.

3. Instruct the client to fast for 12 hours.

4. Place the client on her left side.

14. Which intervention should the nurse implement in the client scheduled for amniocentesis?

1. Tell the client to drink 1L of water

2. Have the client void

3. Instruct the client to fast for 12 hours

4. Place the client on her left side

61. Accompanied by her father, a primiparous 15-year-old client arrives for her first prenatal visit at

30 weeks’ gestation. Her father refuses to leave the room, stating that the girl is shy and he will

answer the questions for her. Which aspect of this situation should be of most concern to the nurse?

1. The possibility of preterm labor with an adolescent pregnancy

2. Lack of prenatal care until this visit

3. Possible child abuse or domestic violence

4. Difficulties of an overprotective parent in dealing with his daughter

64. During the second and third trimesters, common pregnancy discomforts may increase in severity.

Which discomforts would the nurse normally expect to see?

1. Ankle edema, hemorrhoids, and nausea and vomiting, and shortness of breath

2. Ankle edema, shortness of breath, leg cramps, and increased vaginal discharge
 3. Leg cramps, Braxton Hicks contractions, and nausea and vomiting

4. Leg cramps, ankle edema, and shortness of breath

51. Immediately after delivery, a nurse assesses the neonate’s respiratory effort as slow. The neonate

is actively moving but grimaces in response to stimulation. His fingers and toes are bluish, and his

heart rate is 130 beats per minute. Which step should the nurse take next?

1. Tell the physician that the neonate appears abnormal

2. Assign an Apgar score of 8

3. Assign an Apgar score of 10

4. Provide oxygen and stimulate the baby to cry

59. A 32-year-old female client has her first prenatal visit at 15 weeks’ gestation. Which finding

during this visit is abnormal?

1. Fundal height of 18cm

2. Blood pressure of 124/72mmHg

3. Urine negative for protein

4. Weight of 144lbs (65.3kg)