NCLEX questions-Maternity (with rationales)
Questions and Correct Detailed Answers (Verified
Answers) ||Already Graded A+||Newest Version
Quiz: 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
Ans: 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.
Quiz: 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
o
o
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in the number given.
, Ans: 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).
Quiz: 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.
Ans: 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.
Quiz: 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
o
o
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in the number given.
, Ans: 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.
Quiz: 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.
Ans: C. Rationale: Tingling fingers and diiness 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.zz
Quiz: 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
o
o
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in the number given.
Questions and Correct Detailed Answers (Verified
Answers) ||Already Graded A+||Newest Version
Quiz: 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
Ans: 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.
Quiz: 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
o
o
© 2025 TestTrackers
WhatsApp or call o Resources & Updates: [Testtrackers - Stuvia US]
[+254707240657] o Your Success is Our Mission!
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in the number given.
, Ans: 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).
Quiz: 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.
Ans: 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.
Quiz: 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
o
o
© 2025 TestTrackers
WhatsApp or call o Resources & Updates: [Testtrackers - Stuvia US]
[+254707240657] o Your Success is Our Mission!
o For online exams and tutor expert, please whatsapp me
in the number given.
, Ans: 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.
Quiz: 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.
Ans: C. Rationale: Tingling fingers and diiness 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.zz
Quiz: 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
o
o
© 2025 TestTrackers
WhatsApp or call o Resources & Updates: [Testtrackers - Stuvia US]
[+254707240657] o Your Success is Our Mission!
o For online exams and tutor expert, please whatsapp me
in the number given.
