Maternal and Newborn Success: A Course Review Applying Critical Thinking Skills to Test Taking eBook


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  • Published: 2009
  • ISBN-10: 0803619065
  • ISBN-13: 978-0803619067


Maternal and Newborn Success, A Course Review Applying Critical Thinking Skills to Test Taking eBook

1 Introduction

This book is part of a series published by the F. A. Davis Company designed to assist

student nurses in reviewing essential information and in taking examinations, particularly

the NCLEX-RN examination and certification exams. The book focuses predominantly

on childbearing—the antepartum, intrapartum, postpartum, and newborn periods—and,

because of the childbearing focus, also includes questions about fetal and neonatal development.

In addition, because women are pregnant for such a short period of their lives,

because childbearing occurs within the context of the family, and because embryonic and fetal

development occur within the context of genetics, the text contains questions on those

topics. Other subjects, including sexually transmitted illnesses, domestic violence, rape, and

contraception that affect women during the childbearing years—which make up about one

third of a woman’s life—are also included. As a result, this text is an excellent supplement

for a number of nursing school courses, including Parent-Child Nursing, Fetal Growth and

Development, Basic Genetics, Family Processes, and Women’s Health.

To obtain the most from this book, the student is strongly encouraged to read the content

related to the different topic areas and to study the material in a logical manner. Only

if this is done will this book be valuable. Used as a supplement to foundational work, this

book should be helpful in developing the skills needed to be successful on examinations,

such as NCLEX and certification exams, in the relevant content areas.

A discussion of the types of questions asked on examinations, of techniques for approaching

test questions in order to identify what is being asked, and of how to select correct responses

is included.


This book contains 11 chapters and is accompanied by a CD-ROM with two comprehensive

examinations. This introductory chapter focuses on the types of questions included

in the NCLEX-RN examination and on how to approach studying and preparing for an

examination. Chapters 2 through 11 focus on topics related to maternity nursing, most

specifically the antepartum, intrapartum, postpartum, and newborn periods. Each of these

chapters contains Practice Questions that test a student’s knowledge and Practice Question

Answers and Rationales with specific tips on how to approach answering the question. The

reasons why a particular answer is correct and the reasons why other answer options are incorrect

are given. These serve as valuable learning tools for the student and help to reinforce

knowledge. The two comprehensive CD-ROM examinations include questions—and

answers—that cover all topics included in the 10 content chapters. The CD-ROM format

will provide the test taker with practice in answering questions on the computer, a valuable

help since the NCLEX-RN examination is computer based.


The first step, before attempting to answer questions in this text—or on an examination—

is to study and learn the relevant material. Learning does not mean simply reading textbooks

and/or attending class. Learning is an active process that requires a number of complex

skills, including reading, discussing, and organizing information.



Students must first read their assignments. And, by far, the best time to read the assigned

material is before the class in which the information will be discussed. Then, if students

have any questions about what was read, they can ask the professor during class and clarify

anything that is confusing. In addition, students will find discussions much more meaningful

when they have a basic understanding of the material.


During class time, material should be discussed with students rather than fed to them. Certainly,

professors have an obligation to provide stimulating and thought-provoking classes,

but students also have an obligation to be prepared to engage in discussions upon entering

the classroom.

Although facts must be learned, nursing is not a fact-based profession. Nursing is an applied

science. Nurses must know information but, more importantly, they must use information.

When a nurse enters a client’s room, the client rarely asks the nurse to define a

term or to recite a fact. Rather the client presents the nurse with a set of data that the nurse

must interpret and act on. In other words, the nurse must think critically. Students, therefore,

must discuss client-based information by asking “why” questions rather than simply

learning facts by asking “what” questions.


While reading and discussing information, nursing students must begin to organize their

knowledge. Nursing knowledge cannot be memorized! There is too much information to

be memorized and, more important, memorization negatively affects the ability to use information.

Nurses must be able to analyze data critically in order to determine priorities

and actions. In order to think critically, nurses must have developed connections between

and among information.

There are several steps in a pathway for organizing basic information, including understanding

the pathophysiology of the problem; determining its significance for the particular

client; identifying signs and symptoms; and using the steps of the nursing process: assessment,

formulation of a nursing diagnosis, development of a plan of care, implementation of

that plan, and evaluation of the outcomes. An example—a woman with a medical diagnosis

of placenta previa—is used below and throughout the remainder of this chapter to illustrate

the use of these interrelated steps to provide a pathway for organizing basic information.

Whether studying for an examination or using skills in a specific clinical situation, it is often

helpful to show graphically the relationships between and among various pieces of information,

as is also done below.

Example: A client has placenta previa.

The nurse must first understand the problem, determine its significance, and assess for

signs and symptoms.

Understand the Problem

The first action is to understand (not memorize) the pathophysiology of the issue or

problem. (Implicit in this example is the prerequisite that the learner already fully understands

the normal anatomy and physiology of pregnancy.)

The placenta usually attaches to a highly vascular site in the decidua on the posterior wall

of the uterus. Women who have compromised uterine vascularity—women who are multiparous,

are smokers, have diabetes, or are carrying multiple gestations, for example—are at

high risk for placenta previa. In this condition, the placenta, rather than attaching to the

posterior portion of the uterine wall, attaches to an area immediately above or adjacent to

the internal os of the uterus.

Determine the Significance of the Pathophysiology

The second phase of the process is to determine the significance of the pathophysiology.

Often the nurse is able to deduce the significance based on knowledge of normal anatomy

and physiology.

Because the placenta is the highly vascular organ that supplies oxygen and nutrients to

the developing baby, it is essential to the well-being of the fetus. If the cervix were to dilate

or be injured, the chorionic villi of the placenta would be disrupted. The mother would

lose blood, and the baby’s oxygenation and nutrition would be critically affected, resulting

in a life-threatening situation for both mother and fetus.


Predisposing factors:

too little intrauterine space/

poor vascularity of the decidua

Placenta attaches to area

immediately above or adjacent

to the internal os of the uterus

Predisposing factors:

too little intrauterine space/

poor vascularity of

the decidua

Placenta attaches to area

immediately above or

adjacent to the internal

cervical os

Cervical dilation and/or

placental injury

vaginal bleeding and

fetal hypoxia

Identify Signs and Symptoms

Once the significance of the pathophysiology is deduced, it is essential to identify the signs

and symptoms that are expected.

In the mother, the nurse would expect to see bleeding with its associated changes in

hematological signs (hematocrit and hemoglobin), vital signs, and anxiety.

Because the placental bleeding will be unobstructed—that is, the blood will be able to escape

easily via the vagina, the nurse would expect that the client would be in little to no pain

and that the blood would be bright red. In addition, the nurse would expect the client’s

hematological signs to be affected and the vital signs to change. However, because women

have significantly elevated blood volumes during pregnancy, the pulse rate will elevate first,

while the blood pressure will stay relatively stable. A drop in blood pressure is a late, and

ominous, sign. In addition, the nurse would expect the mother to be anxious regarding her

own and her baby’s well-being.

In the fetus, if there were significant maternal blood loss and placental disturbance, the

nurse would expect to see adverse changes in heart rate patterns. Late decelerations result

from poor uteroplacental blood flow.

Predisposing factors:

too little intrauterine space/

poor vascularity of

the decidua

Placenta attaches to area

immediately above or

adjacent to the internal

cervical os

Cervical dilation

vaginal bleeding and

fetal hypoxia

Mother: bright red,

painless bleeding;

pulse rate;

hgb and hct;

BP late sign;


Fetus: late decelerations

seen on external fetal

monitor tracing

Once the problem and the data concerning it are understood, the significance determined,

and expected signs and symptoms identified, it is time for the student (and nurse) to

turn to the nursing process.


The nursing process is foundational to nursing practice. To provide comprehensive care to

their clients, nurses must understand and use each part of the nursing process—assessment,

formulation of a nursing diagnosis, development of a plan of care, implementation of that

plan, and evaluation of the outcomes.


Nurses gather a variety of information during the assessment phase of the nursing process.

Some of the information is objective, or fact-based. For example, noting a client’s hematocrit

and noting other blood values in the chart are fact-based data that the nurse can use

to determine a client’s needs. But, in addition, nurses must identify subjective data, or information

as perceived through the eyes of the client. A client’s rating of her pain is an excellent

example of subjective information. Nurses must be aware of which data must be assessed

since each and every client situation is unique. In other words, nurses must be able

to use the information taught in class and individualize it for each client interaction in order

to determine which objective data must be accessed and which questions should be

asked of the client. Once the data have been obtained, the nurse analyzes the information,

as noted above.

Formulation of a Nursing Diagnosis

After the nurse has analyzed the data from his or her assessments, a nursing diagnosis is

made. Nurses are licensed to treat actual or potential health problems. Nursing diagnoses

are statements of the health problems that the nurse, in collaboration with the client, has

concluded are critical to the client’s well-being.

Example (continued)

Based on the data above, the nurse now must develop the nursing diagnoses and prioritize

the diagnoses as they relate to the care of a client with placenta previa. Since a

woman with placenta previa may or may not begin to bleed, it is essential that the nurse

develop two sets of diagnoses: one aimed at preventing complications—that is, “risk for”

diagnoses—and one directed at the worst-case scenario—that is, if the client should start

to bleed.

The “risk for” nursing diagnoses for the example given above are:

• Risk for maternal imbalanced fluid volume related to (r/t) hypovolemia secondary to excessive

blood loss

• Risk for impaired fetal gas exchange r/t decreased blood volume and maternal cardiovascular


• Maternal anxiety r/t concern for personal and fetal health

The worst-case scenario (active bleeding) nursing diagnoses are:

• Imbalanced maternal fluid volume r/t hypovolemia secondary to excessive blood loss

• Impaired fetal gas exchange r/t decreased blood volume and maternal cardiovascular


• Maternal anxiety r/t concern for personal and fetal health

Development of a Plan of Care

During the planning phase, the nurse develops a plan of care including goals of care,

expected client outcomes, and interventions necessary to achieve the goals and outcomes.

In other words, the nurse determines what he or she wishes to achieve in relation

to each of the nursing diagnoses and how he or she expects to go about meeting

those goals.


One very important part of this process is the development of the priorities of care. The

nurse must determine which diagnoses are the most important and, consequently, which

actions are the most important. For example, a client’s physical well-being must take precedence

over his or her emotional well-being. Plus, it is essential that the nurse consider the

client’s own priorities. And, of course, nurses must consider the goals and orders of the

client’s primary health care provider.

Example (continued)

The nurse develops a plan of care based on the nursing diagnoses listed above. Since the

physical conditions must take precedence, the nurse prioritizes the plan with the physical

needs first. The client’s emotional needs will then be considered.

The plan of care to meet the “at risk” nursing diagnoses is shown in Box 1-1 and a plan

for the worst-case scenario—active bleeding—is shown in Box 1-2.


Once the plan is established, the nurse then implements the plan. The plan may include

direct client care by the nurse and/or care that is coordinated by the nurse but performed

by other practitioners. It is important to note that if assessment data change during the implementation

phase, the nurse must reanalyze the data, change diagnoses, and reprioritize

his or her care.

One very important aspect of any and all nursing care is that it be evidence-based.

Nurses are independent practitioners. They are mandated to provide safe, therapeutic care

that has a scientific basis. Nurses, therefore, must engage in life-long learning. It is essential

that nurses realize that much of the information in textbooks is outdated before the text

was even published. In order to provide evidence-based care, nurses must keep their knowledge

current by accessing information from reliable sources on the Internet, in professional

journals, and at professional conferences.


The plan should be implemented as developed during the planning phase. If a situation

should change, for example, the woman should begin to bleed spontaneously during a shift,

the nurse would immediately revise his or her plan, as needed. In the example cited, the

nurse would implement the active bleeding plan of care.


BOX 1-1 Plan of Care for Client with Placenta Previa at Risk for Bleeding

Nursing Diagnosis: Risk for imbalanced fluid volume (maternal) related to (r/t) hypovolemia

secondary to excessive blood loss.

Goal: Client will not bleed throughout the pregnancy.

Proposed Actions: The nurse will:

• Assess for vaginal bleeding each shift.

• Assess for uterine contractions each shift.

• Assess vital signs each shift.

• Assess intake and output during each shift.

• Assess bowel function each shift.

• Insert nothing into the vagina.

• Maintain client on bed rest, as ordered.

• Monitor changes in laboratory data, as ordered.

Nursing Diagnosis: Risk for impaired gas exchange (fetal) r/t decreased blood volume and maternal

cardiovascular compromise.

Goal: The fetal heart rate will show average variability and no decelerations until delivery.

Proposed Actions: The nurse will:

• Monitor fetal heart rate every shift.

• Do nonstress testing, as ordered.

Nursing Diagnosis: Anxiety (maternal) r/t concern for personal and fetal health.

Goal: The mother will exhibit minimal anxiety throughout her pregnancy.

Proposed Actions: The nurse will:

• Provide emotional support.


The evaluation phase is usually identified as the last phase of the nursing process, but it also

could be classified as another assessment phase. When nurses evaluate, they are reassessing

clients to determine whether or not the actions taken during the implementation phase met

the needs of the client. In other words, “Were the goals of the nursing care met?” If the

goals were not met, the nurse is obligated to develop new actions to meet the goals. If some

of the goals were met, priorities may need to be changed. And, so on. As can be seen from

this phase, the nursing process is ongoing and ever changing.

Example (continued)

Throughout the nursing care period, the nurse is assessing and reassessing the situation.

If needed, the nurse may report significant changes to the health care provider or may independently

determine that a change in nursing care is needed. For example, if the client

begins to cry because she is concerned about her baby’s health, and physiologically the client

is stable, the nurse can concentrate on meeting the client’s emotional needs. The nurse may

sit quietly with the client while she communicates her concerns. Conversely, if the client

begins to bleed profusely, the nurse would immediately report the change to the client’s

health care provider and implement the active bleeding plan.


There are four Integrative Processes upon which questions on the NCLEX-RN are based:

The Nursing Process, Caring, Communication and Documentation, and Teaching/Learning

(Test Plan for NCLEX-RN 2007). The test taker must determine which process(es) is (are)

being evaluated in each question. In other words, the test taker must realize that

because nursing is an action profession, the NCLEX-RN questions simulate, in a written format,

clinical situations. Critical reading by the test taker is, therefore, essential.


BOX 1-2 Plan of Care for Patient with Placenta Previa Who Is Bleeding

Nursing Diagnosis: Imbalanced fluid volume (maternal) r/t hypovolemia secondary to excessive

blood loss.

Goal: Client will become hemodynamically stable.

Proposed Interventions: The nurse will:

• Measure vaginal bleeding.

• Count number of saturated vaginal pads.

• Weigh pads—1 gm  1 mL of blood.

• Monitor for uterine contraction pattern, if present.

• Assess vital signs every 15 minutes.

• Assess oxygen saturation levels continually.

• Assess intake and output every hour.

• Insert nothing into the vagina.

• Maintain client on bed rest.

• Monitor changes in laboratory data, as ordered.

• Administer intravenous fluids, as ordered.

• Prepare for emergency Cesarean section, as ordered.

Nursing Diagnosis: Risk for impaired gas exchange (fetal) r/t decreased blood volume and

maternal cardiovascular compromise.

Goal: The fetal heart rate will show average variability and no late decelerations.

Proposed Interventions: The nurse will:

• Monitor fetal heart rate continually via external fetal monitor.

Nursing Diagnosis: Anxiety (maternal) r/t concern for personal and fetal health

Goal: The mother will exhibit minimal anxiety.

Proposed Interventions: The nurse will:

• Provide clear, calm explanations of all assessments and actions.

• Provide emotional support.

Most of the questions asked on the NCLEX-RN exam are multiple choice questions.

Other types of questions, known as alternate-type questions, include fill-in-the-blank questions,

multiple-response questions, drag-and-drop questions, hot spot items, and chart or

exhibit items. The types of questions and examples of each are discussed below.

Multiple-Choice Questions

In multiple-choice questions, a stem is provided and the test taker must choose among four

possible responses. Sometimes the test taker will be asked to choose the best response,

sometimes to choose the first action that should be taken, and the like. There are numerous

ways that multiple-choice questions may be asked. Below is but one example related to

a client with placenta previa.

Example: A client, 36 weeks’ gestation, has been diagnosed with a complete placenta

previa. The client tells the nurse that she has a bad backache that comes and goes. Which

of the following actions should the nurse perform first?

1. Give the client a back rub.

2. Assess the client’s vital signs.

3. Time the client’s back pains.

4. Assess for vaginal bleeding.

Answer: 4

The nurse must realize that since the backache comes and goes that this client may be in

early labor. And since dilation of the cervix can lead to bleeding, the nurse must first assess

for placental injury—vaginal bleeding.

Fill-in-the-Blank Questions

Fill-in-the-blank questions are calculation questions. The test taker may be asked to calculate

a medication dosage, an intravenous (IV) drip rate, a minimum urinary output, or other

factor. Included in the question will be the units that the test taker should have in the answer.

Example: The nurse caring for a client with placenta previa must determine how much

blood the client has lost. The nurse weighs a clean vaginal pad (5 gm) and the client’s saturated

pad (25 gm). How many milliliters of blood has the client lost? ____ mL

Answer: 20 mL.

The test taker must subtract 5 from 25 to determine that the client has lost 20 gm of

blood. Then, knowing that 1 gm of blood is equal to 1 mL of blood, the test taker knows

that the client has lost 20 mL of blood.

Drag-and-Drop Questions

In drag-and-drop questions, the test taker is asked to place four or five possible responses

in chronological or rank order. The responses may be actions to be taken during a nursing

procedure, steps in growth and development, and the like. The items are called drag-anddrop

questions since the test taker will move the items with his or her computer mouse.

Needless to say, in this book, the test taker will simply be asked to write the responses in

the correct sequence.

Example: The nurse must administer a blood transfusion to a client with placenta previa

who has lost a significant amount of blood. Please put the following nursing actions in

the chronological order in which they should be performed.

1. Stay with client for a full 5 minutes and take a full set of vital signs.

2. Compare the client’s name and hospital identification number with the name and number

on the blood product container.

3. Check the physician’s order regarding the type of infusion that is to be administered.

4. Regulate the infusion rate as prescribed.


Answer: 3, 2, 4, 1

Of the four steps included in the answer options, the order should be 3, 2, 4, 1. The nurse

must first check the physician’s order to determine exactly what blood product is being ordered.

Second, the nurse must compare the information on the blood product bag with the

client’s name band. This must be done with another nurse or a doctor. Third, the nurse

must begin the infusion and regulate the infusion. Finally, the nurse must closely monitor

the client during the first 5 minutes of the infusion to assess for any transfusion reactions.

At the end of the 5 minutes, a full set of vital signs must be taken.

Multiple-Response Questions

When the test taker sees the statement “Select all that apply” after a question, he or she

should know that the examiner has included more than one correct response to the question.

Usually there will be five responses given and the test taker must determine which of

the five responses are correct. There may be two, three, four, or even five correct responses.

Example: A nurse is caring for a client, 28 weeks’ gestation, with placenta previa. Which

of the following physician orders should the nurse question? Select all that apply.

1. Encourage ambulation.

2. Weigh all vaginal pads.

3. Assess cervical dilation daily.

4. Perform a nonstress test every morning.

5. Administer Colace 100 mg PO three times a day

Answer: 1 and 3 are correct.

Because the placenta could be injured, no vaginal examinations should be performed;

therefore, the nurse should question #3—assess cervical dilation daily. Also, because bleeding

may occur, clients with placenta previa are allowed only minimal activity; therefore, ambulation

would not be encouraged.

Hot Spot Items

Hot spot items require the test taker to identify on a picture, graph, or other image, the correct

response to a question. For example, a test taker may be asked to place an “X” on the

location of a P wave on an electrocardiogram strip.

Example: Below is a diagram of the uterus. Place an “X” where a complete placenta previa

would be attached.

Answer: The test taker should place an “X” on the internal os of the cervix.


Chart/Exhibit Items

Some questions may include a chart or exhibit. The test taker is asked to interpret the data,

identify the locations of data, or perform a calculation based on information given in the


Example: While caring for a client who had an emergency cesarean section because of

active bleeding related to complete placenta previa, the nurse aide has emptied the Foley

catheter three times during an 8-hour shift. How many mL of urine has the client voided

during the shift?

Answer: 250 mL (60 + 90 + 100 = 250)


Urine Output for 8-Hour Shift

7 a.m.

8 a.m. 60 mL

9 a.m.

10 a.m.

11 a.m. 90 mL

12 p.m.

1 p.m.

2 p.m.

3 p.m. 100 mL



There are several techniques that a test taker should use when approaching examination


• Pretend that the examination is a clinical experience—First and foremost, test takers

must approach critical thinking questions as if they were in a clinical setting and the situation

were developing in situ. Virtually all critical-thinking questions are clinically

focused. If the test taker pretends he or she is in a clinical situation, the importance of

the response becomes evident. In addition, the test taker is likely to prepare for the examination

with more commitment. That is not to say that students are rarely committed

to doing well on examinations, but rather that they often approach examinations differently

than they approach clinical situations. It is a rare nurse who goes to clinical not

having had sufficient sleep to care for his or her clients, and yet students often enter an

examination room after only 2 or 3 hours of sleep. The student needs the same critical

thinking ability that sleep provides when in an exam as a nurse needs on a clinical unit.

It is essential that test takers be well rested before all exams.

• Read the stem carefully before reading the responses—As discussed above, there are

a number of different types of questions on the NCLEX-RN examination and most faculty

are including alternate-format questions in their classroom examinations as well. Before

answering any question, the test taker must be sure, therefore, what the questioner

is asking. This is one enormous drawback of classroom examinations. A test taker standing

in a client’s room is much less likely to misinterpret the situation when he or she is

facing a client than when reading a question on an examination.

• Consider possible responses—After clearly understanding the stem of the question, but

before reading the possible responses, the test taker should consider possible correct answers

to the question. It is important for the test taker to realize that test writers only include

plausible answer options. A test writer’s goal is to determine whether or not the test taker

knows and understands the material. The test taker, therefore, must have an idea of what

the correct answer might be before beginning to read the possible responses.

• Read the responses—Only after clearly understanding what is being asked and after developing

an idea of what the correct answer might be should the test taker read the responses.

The one response that is closest in content to the test taker’s “guess” should be

the answer that is chosen, and the test taker should not second guess himself or herself.

The first impression is almost always the correct response. Only if the test taker knows

that he or she misread the question, should the answer be changed.

• Read the rationales for each question—In this book, rationales are given for each answer

option. The student should take full advantage of this feature. Read why the correct answer

is correct. The rationale may be based on content, on interpretation of information,

or on a number of other bases. Understanding why the answer to one question is correct is

likely to transfer over to other questions with similar rationales. Next, read why the wrong

answers are wrong. Again, the rationales may be based on a number of different factors.

Understanding why answers are wrong also may transfer over to other questions.

• Finally, read all test taking tips—Some of the tips relate directly to test-taking skills,

while others include invaluable information for the test taker.

If the test taker uses this text as recommended above, he or she should be well prepared

to be successful when taking an examination in any or all of the content areas represented.

And, as a result, the test taker should be fully prepared to function as a beginning registered

professional nurse in the many areas of maternity and women’s health.

Maternal and Newborn Success, A Course Review Applying Critical Thinking Skills to Test Taking eBook