NCLEX-RN EXAMINATION: 40 EXAM QUESTIONS AND
ANSWERS, UPDATED 2026, GRADED A+
A nurse is preparing to perform a physical examination on a postpartum
client. The client asks the nurse why gloves are necessary for the
examination. What is the nurse's best response?
"Gloves help protect you against infectious organisms."
"Gloves guard you against my cold hands."
"Gloves may protect me against infectious organisms."
"Gloves are required for standard precautions." - CORRECT ANSWER-
Wearing gloves whenever exposure to blood or body fluids is anticipated is
a standard precaution recommended by the Centers for Disease Control
and Prevention. Although gloves protect both the client and the nurse from
infectious organisms and guard against the nurse's cold hands, the nurse
wears them primarily to maintain standard precautions, which is required by
the Occupational Safety and Health Administration.
Which situations should a supervisor consider in making assignments for
nurses in the neonatal unit?
A pregnant nurse shouldn't care for a neonate whose mother was positive
for human immunodeficiency virus (HIV).
A nurse with young children shouldn't care for a neonate whose mother has
gonorrhea.
A nurse with young children shouldn't care for a neonate with erythema
toxicum.
A pregnant nurse shouldn't care for a neonate with cytomegalovirus (CMV).
- CORRECT ANSWER-CMV exposure can affect the fetus; women who
are pregnant should avoid contact with CMV-positive clients. HIV is
transmitted via blood and body fluids; all staff should take contact
,precautions. When a mother has gonorrhea, a nurse should administer eye
prophylaxis to the neonate to prevent neonatal ophthalmic infection. It isn't
a concern for staff. Erythema toxicum is a common rash in infancy;
communicability isn't a concern.
The nurse is developing a care plan for a client with an episiotomy. Which
interventions would be included for the nursing diagnosis acute pain related
to perineal sutures? Select all that apply.
Apply an ice pack intermittently to the perineal area for 3 days.
Avoid the application of topical pain gels.
Administer sitz baths three to four times per day.
Encourage the client to do Kegel exercises.
Limit the number of times the perineal pad is changed. - CORRECT
ANSWER-Sitz baths help decrease inflammation and tension in the
perineal area. Kegel exercises improve circulation to the area and help
reduce edema. Ice packs should be applied to the perineum for only the
first 24 hours; after that time, heat should be used. Topical pain gels should
be applied to the suture area to reduce discomfort, as ordered. The
perineal pad should be changed frequently to prevent irritation caused by
the discharge.
When performing an initial assessment of a postterm male neonate
weighing 4,000 g (8 lb, 13 oz) who was admitted to the observation nursery
after a vaginal birth with low forceps, the nurse detects Ortolani's sign.
Which action should the nurse take next?
Determine the length of the mother's labor.
Notify the health care provider (HCP) immediately.
Keep the neonate under the radiant warmer for 2 hours.
, Obtain a blood sample to check for hypoglycemia. - CORRECT ANSWER-
Ortolani maneuver involves flexing the neonate's knees and hips at right
angles and bringing the sides of the knees down to the surface of the
examining table. A characteristic click or "clunk," felt or heard, represents a
positive Ortolani sign, suggesting a possible hip dislocation. The nurse
should notify the HCP promptly because treatment is needed, while
maintaining the dislocated hip in a position of flexion and abduction. It
should be noted that many institutions now limit performing the Ortolani's
maneuver to APNs or HCPs. Determining the length of the mother's labor
provides no useful information related to the nurse's finding. Keeping the
infant under the radiant warmer is necessary only if the neonate's
temperature is low or unstable. Checking for hypoglycemia is not indicated
at this time, unless the neonate is exhibiting jitteriness.
The nurse is caring for a newborn of a primiparous woman with insulin-
dependent diabetes. When the mother visits the neonate at 1 hour after
birth, the nurse explains to the mother that the neonate is being closely
monitored for symptoms of hypoglycemia because of which reason?
increased use of glucose stores during a difficult labor and birth process
interrupted supply of maternal glucose and continued high neonatal insulin
production
a normal response that occurs during transition from intrauterine to
extrauterine life
increased pancreatic enzyme production caused by decreased glucose
stores - CORRECT ANSWER-Glucose crosses the placenta, but insulin
does not. Hence, a high maternal blood glucose level causes a high fetal
blood glucose level. This causes the fetal pancreas to secrete more insulin.
At birth, the neonate loses the maternal glucose source but continues to
produce much insulin, which commonly causes a drop in blood glucose
levels (hypoglycemia), usually at 30 to 60 minutes postpartum. Most
neonates do not develop hypoglycemia if their mothers are not insulin
ANSWERS, UPDATED 2026, GRADED A+
A nurse is preparing to perform a physical examination on a postpartum
client. The client asks the nurse why gloves are necessary for the
examination. What is the nurse's best response?
"Gloves help protect you against infectious organisms."
"Gloves guard you against my cold hands."
"Gloves may protect me against infectious organisms."
"Gloves are required for standard precautions." - CORRECT ANSWER-
Wearing gloves whenever exposure to blood or body fluids is anticipated is
a standard precaution recommended by the Centers for Disease Control
and Prevention. Although gloves protect both the client and the nurse from
infectious organisms and guard against the nurse's cold hands, the nurse
wears them primarily to maintain standard precautions, which is required by
the Occupational Safety and Health Administration.
Which situations should a supervisor consider in making assignments for
nurses in the neonatal unit?
A pregnant nurse shouldn't care for a neonate whose mother was positive
for human immunodeficiency virus (HIV).
A nurse with young children shouldn't care for a neonate whose mother has
gonorrhea.
A nurse with young children shouldn't care for a neonate with erythema
toxicum.
A pregnant nurse shouldn't care for a neonate with cytomegalovirus (CMV).
- CORRECT ANSWER-CMV exposure can affect the fetus; women who
are pregnant should avoid contact with CMV-positive clients. HIV is
transmitted via blood and body fluids; all staff should take contact
,precautions. When a mother has gonorrhea, a nurse should administer eye
prophylaxis to the neonate to prevent neonatal ophthalmic infection. It isn't
a concern for staff. Erythema toxicum is a common rash in infancy;
communicability isn't a concern.
The nurse is developing a care plan for a client with an episiotomy. Which
interventions would be included for the nursing diagnosis acute pain related
to perineal sutures? Select all that apply.
Apply an ice pack intermittently to the perineal area for 3 days.
Avoid the application of topical pain gels.
Administer sitz baths three to four times per day.
Encourage the client to do Kegel exercises.
Limit the number of times the perineal pad is changed. - CORRECT
ANSWER-Sitz baths help decrease inflammation and tension in the
perineal area. Kegel exercises improve circulation to the area and help
reduce edema. Ice packs should be applied to the perineum for only the
first 24 hours; after that time, heat should be used. Topical pain gels should
be applied to the suture area to reduce discomfort, as ordered. The
perineal pad should be changed frequently to prevent irritation caused by
the discharge.
When performing an initial assessment of a postterm male neonate
weighing 4,000 g (8 lb, 13 oz) who was admitted to the observation nursery
after a vaginal birth with low forceps, the nurse detects Ortolani's sign.
Which action should the nurse take next?
Determine the length of the mother's labor.
Notify the health care provider (HCP) immediately.
Keep the neonate under the radiant warmer for 2 hours.
, Obtain a blood sample to check for hypoglycemia. - CORRECT ANSWER-
Ortolani maneuver involves flexing the neonate's knees and hips at right
angles and bringing the sides of the knees down to the surface of the
examining table. A characteristic click or "clunk," felt or heard, represents a
positive Ortolani sign, suggesting a possible hip dislocation. The nurse
should notify the HCP promptly because treatment is needed, while
maintaining the dislocated hip in a position of flexion and abduction. It
should be noted that many institutions now limit performing the Ortolani's
maneuver to APNs or HCPs. Determining the length of the mother's labor
provides no useful information related to the nurse's finding. Keeping the
infant under the radiant warmer is necessary only if the neonate's
temperature is low or unstable. Checking for hypoglycemia is not indicated
at this time, unless the neonate is exhibiting jitteriness.
The nurse is caring for a newborn of a primiparous woman with insulin-
dependent diabetes. When the mother visits the neonate at 1 hour after
birth, the nurse explains to the mother that the neonate is being closely
monitored for symptoms of hypoglycemia because of which reason?
increased use of glucose stores during a difficult labor and birth process
interrupted supply of maternal glucose and continued high neonatal insulin
production
a normal response that occurs during transition from intrauterine to
extrauterine life
increased pancreatic enzyme production caused by decreased glucose
stores - CORRECT ANSWER-Glucose crosses the placenta, but insulin
does not. Hence, a high maternal blood glucose level causes a high fetal
blood glucose level. This causes the fetal pancreas to secrete more insulin.
At birth, the neonate loses the maternal glucose source but continues to
produce much insulin, which commonly causes a drop in blood glucose
levels (hypoglycemia), usually at 30 to 60 minutes postpartum. Most
neonates do not develop hypoglycemia if their mothers are not insulin
