NCLEX questions-Maternity (with
rationales)
A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia
(PCA) pump for pain control. Her oral intake has been ice chips only since su
...
NCLEX questions-Maternity (with
rationales)
A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia
(PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now
complaining of nausea and bloating, and states that because she had nothing to eat, she is too
weak to breastfeed her infant. Which nursing diagnosis has the highest priority?
A. Altered nutrition, less than body requirements for lactation
B. Alteration in comfort related to nausea and abdominal distention
C. Impaired bowel motility related to pain medication and immobility
D.NFatigue related to cesarean delivery and physical care demands of infant - ✔✔C. Rationale:
Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility (C) is
the priority nursing diagnosis and addresses the potential problem of a paralytic ileus. (A and B)
are both caused by impaired bowel motility. (D) is not as important as impaired motility.
The nurse is teaching care of the newborn to a childbirth preparation class and describes the need
for administering antibiotic ointment into the eyes of the newborn. An expectant father asks,
"What type of disease causes infections in babies that can be prevented by using this ointment?"
Which response by the nurse is accurate?
A.NHerpes
B. Trichomonas
C. Gonorrhea
D. Syphilis - ✔✔C. Rationale: Erythromycin ointment is instilled into the lower conjunctiva of
each eye within 2 hours after birth to prevent ophthalmia neonatorum, an infection caused by
gonorrhea (C), and inclusion conjunctivitis, an infection caused by Chlamydia. The infant may
be exposed to these bacteria when passing through the birth canal. Ophthalmic ointment is not
effective against (A, B, or D).
A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting
motions and will not grasp the nipple. Which intervention should the nurse implement?
A. Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking.
B. Hold the infant's head firmly against the breast until he latches onto the nipple.
C. Encourage the mother to stop feeding for a few minutes and comfort the infant.
D. Provide formula for the infant until he becomes calm, and then offer the breast again. - ✔✔C.
Rationale: The infant is becoming frustrated and so is the mother; both need a time out. The
mother should be encouraged to comfort the infant and to relax herself (C). After such a time
out, breastfeeding is often more successful. (A and D) would cause nipple confusion. (B) would
only cause the infant to be more resistant, resulting in the mother and infant to become more
frustrated.
The nurse is counseling a couple who has sought information about conceiving. The couple asks
the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct?
A. Two weeks before menstruation
B. Immediately after menstruation
C. Immediately before menstruation
D. Three weeks before menstruation - ✔✔A. Rationale: Ovulation occurs 14 days before the
first day of the menstrual period (A). Although ovulation can occur in the middle of the cycle or
2 weeks after menstruation, this is only true for a woman who has a perfect 28-day cycle. For
many women, the length of the menstrual cycle varies. (B, C, and D) are incorrect.
The nurse instructs a laboring client to use accelerated blow breathing. The client begins to
complain of tingling fingers and dizziness. Which action should the nurse take?
A. Administer oxygen by face mask.
B. Notify the health care provider of the client's symptoms.
C. Have the client breathe into her cupped hands.
D. Check the client's blood pressure and fetal heart rate. - ✔✔C. Rationale: Tingling fingers and
dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation
is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or
cupped hands (C). (A) is inappropriate because the carbon dioxide level is low, not the oxygen
level. (B and D) are not specific for this situation.
When assessing a client at 12 weeks of gestation, the nurse recommends that she and her
husband consider attending childbirth preparation classes. When is the best time for the couple to
attend these classes?
A. At 16 weeks of gestation
B. At 20 weeks of gestation
C. At 24 weeks of gestation
D. At 30 weeks of gestation - ✔✔D. Rationale: Learning is facilitated by an interested pupil.
The couple is most interested in childbirth toward the end of the pregnancy, when they are
beginning to anticipate the onset of labor and the birth of their child. (D) is closest to the time
when parents would be ready for such classes. (A, B, and C) are not the best times during a
pregnancy for the couple to attend childbirth education classes. At these times they will have
other teaching needs. Early pregnancy classes often include topics such as nutrition, physiologic
changes, coping with normal discomforts of pregnancy, fetal development, maternal and fetal
risk factors, and evolving roles of the mother and her significant others.
One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96°
F, his lower lip is shaking and, when the nurse assesses for a Moro reflex, the boy's hands shake.
Which intervention should the nurse implement first?
A. Stimulate the infant to cry.
B. Wrap the infant in warm blankets.
C. Feed the infant formula.
D. Obtain a serum glucose level. - ✔✔D. Rationale: This infant is demonstrating signs of
hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine
the serum glucose level (D). (A) is an intervention for a lethargic infant. (B) should be done
based on the temperature, but first the glucose level should be obtained. (C) helps raise the blood
sugar, but first the nurse should determine the glucose level.
Which statement made by the client indicates that the mother understands the limitations of
breastfeeding her newborn?
A. "Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period."
B. "Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the
alcohol to clear my breast milk. "
C. "I can start smoking cigarettes while breastfeeding because it will not affect my breast milk. "
D. "When I take a warm shower after I breastfeed, it relieves the pain from being engorged
between breastfeedings. " - ✔✔A. Rationale: Continuous breastfeeding on a 3- to 4-hour
schedule during the day will cause a release of prolactin, which will suppress ovulation and
menses, but is not completely effective as a birth control method (A). (B) is incorrect because
alcohol can immediately enter the breast milk. Nicotine is transferred to the infant in breast milk
(C). Taking a warm shower will stimulate the produ
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