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Qualifier in the Exam Item: Which action would you take FIRST?

When taking the exam, it's important to look for a first qualifier in the exam item.

In an earlier post, I talked about qualifiers in the stem of an exam item. But recently, several people have asked me for more help dealing with exam items that have a “first” qualifier.

Here are a few simple tips:

Figure out which “first” you need to respond

On an exam, a qualifier of “first” in the stem could mean:

  • “first” as in sequence
  •  “first” as in priority

Ask yourself: Do I need to determine the first of one or more steps, or prioritize an action?

Let’s break this down a bit.


This type of “first” question is often a “most important” question in disguise. Not always, but it’s likely that such a question requires you to figure out which action is MOST important in order to avert a consequence or a complication.

Ask yourself:

  • Which option would have the biggest impact?
  • Which option would eliminate, or at least minimize a possible consequence?
  • Why wouldn’t the other options work as well?


Ask yourself this: Would one or more of the options listed be a logical second action? If so, it’s highly likely that this “first” question is more about sequencing.

Here are some actions you’d usually take before taking other actions.


True, occasionally there are situations where you already have more than enough information to know what your intervention should be.

But most times, you need to have a better grip on what’s going on before doing any intervention. The first thing you should do is take a history, gather data, or come to an understanding about what’s really happening.

KISS (Keep it simple, stupid)

I was once teaching a live course when someone asked, “Marie, do you always try the simplest thing first?” I suddenly realized, yes, I do! And I would encourage you to do the same, both in real life and on the IBLCE exam.

Don’t get out a pump to evert a nipple if a little gentle rolling or tapping will do the job. Don’t teach the mother a new skill if she just needs a little help mastering an old skill. You get my drift.


I am astonished at how many times a baby totally fakes me out. Sometimes, I think there is no way in creation he is going to make that feeding work. But alas, he does! So allow a baby to try feeding directly at the breast before you start hauling out the fancy equipment.


In many or most cases, it’s best to acknowledge or validate the mother’s feelings before trying to problem-solve, or before giving her options to do her own problem-solving. This becomes even more important in highly emotional situations. Very often, after validating her feelings, you can offer options, or begin to problem-solve.


When the question’s stem describes a fretful, worried mother, the first action is to reassure her that no harm will befall her baby (presuming that’s the case). The next step might be suggesting options, offering an explanation, or perhaps some other action.  

Pick the “textbook” answer

Aw, c’mon, you know what I mean! In real life, you don’t always do everything “by the book.”

In real life, I’m responsible for four couplets and I’m nearly late to do a procedure on a kid, and a doctor is barking verbal orders for a newly-admitted patient. My reflective listening skills go down the tubes. But on the exam, reflective listening and counseling the mother is what to do FIRST.

Here’s another example: even though I’m a huge fan of cup feeding and began doing it in the early 1980s, in all honesty, I don’t always pick it as my “first” suggestion in real life. But I know that, on the exam, that’s the answer.

Remember, it’s about what comes first

Finally, assume that all of the options listed are possible, and doable. But knowing what to do FIRST makes one option correct, and all of the others wrong.

I can’t guarantee that these tips will work every time, but this is how I deal with those pesky “first” qualifiers.

How do you deal with “first” qualifiers in the exam item stem?  Share in the comments below!

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