From "What Is Normal Lochia?" to "Which Patient Do You See First?": Rewriting Test Items and Building an Analytic Rubric for a Maternal-Newborn Course
[Student Name]
University of Phoenix
NSG/533: Educational Assessment and Evaluation
Week 3 Assignment
[Instructor Name]
[Date]
The school, the course and the items are a composite written for a model paper.
In Week 2, I built an assessment blueprint for the maternal-newborn course I lead, requiring that at least 60% of exam items be at the apply level or higher and adding a written case analysis graded by rubric. This paper writes the tools: revised exam items and the case analysis rubric.
Why Item Writing Matters
Poorly written items do not just measure the wrong level; they can measure test-taking skill instead of knowledge. In a study of ten summative nursing exams, a panel found item-writing flaws in 47.3% of all items, with the proportion on individual papers ranging from 28% to 75%. When only unflawed items were counted, fewer students passed, 90.6% compared with 94.3%, while more students scored 80% or higher, 20.9% compared with 14.5% (Tarrant & Ware, 2008). Flawed items blur the difference between students who know the material and students who do not, which is exactly the difference an exam exists to show.
Item Revision 1
Original item, remember level: "What is the normal color of lochia on the first postpartum day? A. Rubra. B. Serosa. C. Alba. D. Clear." Problems: it tests recall of a term; one option, "clear," is implausible; and knowing the answer does not show that a student can act on lochia findings.
Revised item, analyze level: "A 29-year-old gave birth vaginally 18 hours ago. Her fundus is firm, one fingerbreadth below the umbilicus and midline. Her perineal pad, changed 30 minutes ago, is saturated with bright red lochia and small clots. Her pulse has climbed over the past hour, from the high 70s to 96 beats per minute. Which action should the nurse take first? A. Document the findings and reassess in one hour. B. Weigh the pad and assess for a full bladder and perineal bleeding source. C. Encourage the patient to ambulate to improve uterine tone. D. Explain that heavy lochia is expected in the first 24 hours." Correct answer: B. The item requires students to notice that a firm fundus with heavy bleeding and a rising heart rate suggests a source other than uterine atony, to recognize that this is not expected and to choose a focused assessment. Each distractor reflects a real misconception.
Item Revision 2
Original item, remember level: "Which of the following is a normal newborn heart rate? A. 60 to 80. B. 80 to 100. C. 110 to 160. D. 180 to 200." Problems: a single fact, and the distractors are too obviously wrong for many students.
Revised item, apply level: "A term newborn is 40 minutes old and skin to skin with the mother. The nurse finds a respiratory rate of 72 breaths per minute with nasal flaring and intermittent grunting, a heart rate of 158 and a temperature of 36.2 degrees Celsius. What is the nurse's priority action? A. Continue skin-to-skin contact and recheck in one hour. B. Move the newborn to a radiant warmer, assess oxygen saturation and notify the provider. C. Encourage the mother to breastfeed to calm the infant. D. Swaddle the newborn and place in the bassinet." Correct answer: B. The student must interpret signs of respiratory distress together with a low temperature and choose actions that address both.
Item Revision 3
Original item, understand level, negatively worded: "Which of the following is NOT a sign of preeclampsia?" Problem: negative stems confuse students and test reading as much as knowledge.
Revised item, analyze level, prioritization: "The nurse receives report on four postpartum patients. Which patient should the nurse assess first? A. A patient 2 days after cesarean birth requesting pain medication for incision pain rated 6 of 10. B. A patient 12 hours after vaginal birth with a blood pressure of 162/104 mm Hg and a headache. C. A patient 1 day after vaginal birth who has not voided in 5 hours. D. A patient asking for help with breastfeeding latch." Correct answer: B. The item requires comparing four real needs and recognizing that severe-range blood pressure with a headache after birth is an emergency.
Rules Applied to Every Item
Each revised item follows rules drawn from item-writing guidance: a stem that poses a clear clinical question, positively worded; four options of similar length and structure; distractors based on real errors; no "all of the above" or "none of the above"; and only one defensible best answer, checked by a second faculty member (Oermann & Gaberson, 2021).
The Case Analysis Rubric
The written case analysis asks students to evaluate the care given to a woman with postpartum hemorrhage in a detailed case and recommend changes, which measures objective 5 at the evaluate level. The rubric has five criteria, each scored at four levels: exemplary, 4; proficient, 3; developing, 2; and beginning, 1.
Criterion 1, recognition of cues. Exemplary: identifies all relevant cues in the case, including subtle early ones, and explains their significance. Beginning: lists findings without distinguishing relevant from irrelevant.
Criterion 2, evaluation of interventions. Exemplary: judges each nursing intervention against current evidence and the patient's response, identifying what was effective, delayed or missing. Beginning: describes interventions without judging them.
Criterion 3, use of evidence. Exemplary: supports judgments with current, relevant guidelines or research, correctly applied. Beginning: cites no evidence or misapplies it.
Criterion 4, recommendations. Exemplary: proposes specific, feasible changes that address the problems identified, with reasons. Beginning: offers general statements such as "communicate better."
Criterion 5, writing and format. Exemplary: organized, clear, correct APA style. Beginning: disorganized, with frequent errors.
The criteria follow the aspects of clinical judgment described by Lasater (2007), noticing, interpreting, responding and reflecting, adapted from simulation to written case analysis, so that the rubric measures the same thinking as the simulation.
Testing the Items Before Use
Before the new items go on an exam, two faculty who did not write them will answer each one independently and note any confusion, and three recent graduates working in maternal-newborn units will review the scenarios for realism. Items that either faculty member answers differently from the key, or that the graduates find unrealistic, will be revised. This review costs a few hours per exam and prevents the most damaging flaw, an item with no single best answer, from reaching students.
Design Choices in the Rubric
The rubric weights the first four criteria at 22.5% each and writing at 10%, so content outweighs form. Descriptions for each level describe the work, not a quantity, avoiding phrases like "some" or "many" that graders interpret differently. The rubric will be shared with students at the start of the course and used by students to assess a sample paper in class, which also serves as formative assessment.
Conclusion
Three recall items became scenario-based items that ask students to interpret and prioritize, following rules that remove the flaws common in nursing exams. The analytic rubric for the case analysis measures evaluation through five criteria tied to clinical judgment. Week 4 will examine whether these tools are reliable and valid, including an item analysis of the revised exam.
References
Lasater, K. (2007). Clinical judgment development: Using simulation to create an assessment rubric. Journal of Nursing Education, 46(11), 496-503. https://doi.org/10.3928/01484834-20071101-04
Oermann, M. H., & Gaberson, K. B. (2021). Evaluation and testing in nursing education (6th ed.). Springer Publishing.
Tarrant, M., & Ware, J. (2008). Impact of item-writing flaws in multiple-choice questions on student achievement in high-stakes nursing assessments. Medical Education, 42(2), 198-206. https://doi.org/10.1111/j.1365-2923.2007.02957.x
How this NSG 533 Week 3 example is structured
The NSG/533 description emphasizes thoughtful creation of evaluation tools aligned to an educational taxonomy. This paper shows tools being built rather than described: each item appears before and after revision with its taxonomy level and the flaw corrected, and the rubric is presented criterion by criterion with performance levels and the reasoning behind them. Students search this week as NSG 533 Week 3, NSG533 Wk 3 or NSG/533 Wk 3; all three are the same assignment.
NSG/533 Week 3 questions, answered
What does NSG/533 Week 3 usually ask for?
The course description emphasizes creating evaluation tools aligned to a taxonomy. Many sections ask students to write test items or a rubric at specified cognitive levels, with a rationale.
What are common item-writing flaws?
Clues to the correct answer, such as a longer or more detailed correct option, implausible distractors, negatively worded stems, "all of the above" options and stems that do not pose a clear question.
What is an analytic rubric?
A scoring tool that rates several criteria separately, each with descriptions of performance at different levels, so that students receive feedback on each part of their work.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official University of Phoenix document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.