NCLEX RN Health Promotion &
Maintenance Exam 3 Questions And
Correct Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
Download Pdf
1. A 28-year-old primigravida at 12 weeks gestation asks the nurse about the
recommended weight gain during pregnancy. Her prepregnancy body mass
index (BMI) is 22.5. Which response by the nurse is most accurate?
A. "You should gain a total of 11 to 20 pounds during your pregnancy."
B. "The recommended weight gain for your BMI is 25 to 35 pounds."
C. "You need to gain at least 40 pounds to support fetal growth."
D. "Weight gain is not a concern until the third trimester."
Answer: B.
Rationale: According to the Institute of Medicine (IOM) guidelines, a
woman with a normal prepregnancy BMI (18.5–24.9) should gain 25 to 35
pounds total. Option A is for overweight BMI (25–29.9). Option C is for
underweight BMI (<18.5). Option D is incorrect because weight gain
should be monitored throughout pregnancy, with specific goals for each
trimester. Proper weight gain reduces risks of gestational diabetes,
preeclampsia, and fetal macrosomia.
2. A nurse is teaching a 30-year-old woman about self-breast examination
(SBE). Which statement by the client indicates a correct understanding of
the technique?
A. "I should perform SBE on the first day of my menstrual period."
B. "I will examine my breasts while lying down and then while standing in
the shower."
C. "I only need to check for lumps and ignore any nipple discharge."
, D. "I should use the fingertips of my index finger to palpate in a circular
motion."
Answer: B.
Rationale: SBE should be performed 5–7 days after the onset of menses,
when breasts are least congested. Examining both lying (for deep tissue)
and standing (for superficial tissue) is recommended. Option A is wrong
because breasts are tender during menses. Option C is wrong because
nipple discharge, skin changes, and dimpling must be reported. Option D
is wrong because the pads of the middle three fingers should be used, not
just the index finger, to cover all breast tissue.
3. A 42-year-old male is scheduled for a routine health screening. Which
immunization should the nurse recommend for this patient based on
current CDC guidelines?
A. MMR (measles, mumps, rubella) booster
B. Tdap (tetanus, diphtheria, pertussis) every 10 years
C. Varicella vaccine
D. Hepatitis A vaccine
Answer: B.
Rationale: The CDC recommends Tdap every 10 years for all adults. A one-
time Tdap booster is especially important for those who have not received
it, followed by Td every 10 years. MMR is recommended for adults born
after 1957 without evidence of immunity, but it is not a standing universal
recommendation for all ages. Varicella is recommended for those without
immunity, but not all adults need it. Hepatitis A is risk-based, not universal
for all adults.
4. During a prenatal visit, a client at 28 weeks gestation reports frequent
heartburn. Which dietary modification should the nurse suggest to alleviate
this discomfort?
A. Increase intake of fried and spicy foods to stimulate digestion.
B. Eat small, frequent meals and avoid lying down immediately after eating.
C. Drink a full glass of water with every meal to dilute stomach acid.
D. Consume only cold liquids and avoid all hot beverages.
, Answer: B.
Rationale: Heartburn in pregnancy is caused by progesterone-induced
relaxation of the lower esophageal sphincter and pressure from the
growing uterus. Eating small, frequent meals reduces gastric distension,
and avoiding recumbency after meals prevents acid reflux. Option A is
wrong because fried/spicy foods aggravate heartburn. Option C is wrong
because large volumes of fluid can distend the stomach and worsen reflux.
Option D is not evidence-based.
5. A nurse is performing a developmental screening on a 9-month-old infant.
Which finding would indicate a delay that requires further evaluation?
A. The infant can sit without support.
B. The infant babbles and responds to his name.
C. The infant pulls to a standing position and cruises.
D. The infant does not transfer objects from one hand to the other.
Answer: D.
Rationale: At 9 months, infants should be able to transfer objects between
hands, sit unsupported, crawl, and respond to name. Failure to transfer
objects by 9 months may indicate a fine motor delay. Options A, B, and C
are all normal milestones for this age. The Denver Developmental
Screening Test helps identify such delays early.
6. A 65-year-old female is concerned about osteoporosis. The nurse
recommends which screening test as the gold standard for diagnosing this
condition?
A. Serum calcium level
B. DEXA scan (dual-energy X-ray absorptiometry)
C. Plain radiograph of the spine
D. 24-hour urine calcium
Answer: B.
Rationale: DEXA scan is the gold standard for measuring bone mineral
density and diagnosing osteoporosis. Serum calcium and urine calcium are
useful for metabolic workups but do not diagnose osteoporosis. Plain
radiographs only show bone loss after significant demineralization
, (usually >30%). The DEXA provides a T-score that guides treatment
decisions.
7. During a postpartum home visit, the nurse assesses a mother who gave
birth 48 hours ago. The mother reports feeling overwhelmed and tearful.
Which action is most appropriate?
A. Reassure the mother that this is normal and she just needs rest.
B. Assess for additional signs of postpartum depression, such as inability to
care for the baby.
C. Schedule an immediate psychiatric evaluation for severe depression.
D. Advise the mother to stop breastfeeding to reduce stress.
Answer: B.
Rationale: The "baby blues" occur within the first 2–5 days postpartum
and include mood swings, tearfulness, and overwhelm, but these
symptoms resolve spontaneously. However, the nurse must assess for
postpartum depression (PPD) which may present with persistent sadness,
inability to care for self or baby, or thoughts of harm. Option A is
dismissive; the nurse must differentiate. Option C is premature without
further assessment. Option D is not indicated and breastfeeding does not
cause PPD.
8. A 16-year-old male comes for a sports physical. The nurse counsels him
about injury prevention. Which recommendation is most important for this
adolescent?
A. Avoid all contact sports due to risk of concussion.
B. Use properly fitting protective gear and equipment.
C. Drink only water, not sports drinks.
D. Stretch only after exercise, not before.
Answer: B.
Rationale: Properly fitting protective equipment (helmets, pads,
mouthguards) is critical in preventing sports-related injuries, especially
concussions and fractures. Option A is unrealistic; adolescents can
participate in contact sports with appropriate precautions. Option C is
Maintenance Exam 3 Questions And
Correct Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
Download Pdf
1. A 28-year-old primigravida at 12 weeks gestation asks the nurse about the
recommended weight gain during pregnancy. Her prepregnancy body mass
index (BMI) is 22.5. Which response by the nurse is most accurate?
A. "You should gain a total of 11 to 20 pounds during your pregnancy."
B. "The recommended weight gain for your BMI is 25 to 35 pounds."
C. "You need to gain at least 40 pounds to support fetal growth."
D. "Weight gain is not a concern until the third trimester."
Answer: B.
Rationale: According to the Institute of Medicine (IOM) guidelines, a
woman with a normal prepregnancy BMI (18.5–24.9) should gain 25 to 35
pounds total. Option A is for overweight BMI (25–29.9). Option C is for
underweight BMI (<18.5). Option D is incorrect because weight gain
should be monitored throughout pregnancy, with specific goals for each
trimester. Proper weight gain reduces risks of gestational diabetes,
preeclampsia, and fetal macrosomia.
2. A nurse is teaching a 30-year-old woman about self-breast examination
(SBE). Which statement by the client indicates a correct understanding of
the technique?
A. "I should perform SBE on the first day of my menstrual period."
B. "I will examine my breasts while lying down and then while standing in
the shower."
C. "I only need to check for lumps and ignore any nipple discharge."
, D. "I should use the fingertips of my index finger to palpate in a circular
motion."
Answer: B.
Rationale: SBE should be performed 5–7 days after the onset of menses,
when breasts are least congested. Examining both lying (for deep tissue)
and standing (for superficial tissue) is recommended. Option A is wrong
because breasts are tender during menses. Option C is wrong because
nipple discharge, skin changes, and dimpling must be reported. Option D
is wrong because the pads of the middle three fingers should be used, not
just the index finger, to cover all breast tissue.
3. A 42-year-old male is scheduled for a routine health screening. Which
immunization should the nurse recommend for this patient based on
current CDC guidelines?
A. MMR (measles, mumps, rubella) booster
B. Tdap (tetanus, diphtheria, pertussis) every 10 years
C. Varicella vaccine
D. Hepatitis A vaccine
Answer: B.
Rationale: The CDC recommends Tdap every 10 years for all adults. A one-
time Tdap booster is especially important for those who have not received
it, followed by Td every 10 years. MMR is recommended for adults born
after 1957 without evidence of immunity, but it is not a standing universal
recommendation for all ages. Varicella is recommended for those without
immunity, but not all adults need it. Hepatitis A is risk-based, not universal
for all adults.
4. During a prenatal visit, a client at 28 weeks gestation reports frequent
heartburn. Which dietary modification should the nurse suggest to alleviate
this discomfort?
A. Increase intake of fried and spicy foods to stimulate digestion.
B. Eat small, frequent meals and avoid lying down immediately after eating.
C. Drink a full glass of water with every meal to dilute stomach acid.
D. Consume only cold liquids and avoid all hot beverages.
, Answer: B.
Rationale: Heartburn in pregnancy is caused by progesterone-induced
relaxation of the lower esophageal sphincter and pressure from the
growing uterus. Eating small, frequent meals reduces gastric distension,
and avoiding recumbency after meals prevents acid reflux. Option A is
wrong because fried/spicy foods aggravate heartburn. Option C is wrong
because large volumes of fluid can distend the stomach and worsen reflux.
Option D is not evidence-based.
5. A nurse is performing a developmental screening on a 9-month-old infant.
Which finding would indicate a delay that requires further evaluation?
A. The infant can sit without support.
B. The infant babbles and responds to his name.
C. The infant pulls to a standing position and cruises.
D. The infant does not transfer objects from one hand to the other.
Answer: D.
Rationale: At 9 months, infants should be able to transfer objects between
hands, sit unsupported, crawl, and respond to name. Failure to transfer
objects by 9 months may indicate a fine motor delay. Options A, B, and C
are all normal milestones for this age. The Denver Developmental
Screening Test helps identify such delays early.
6. A 65-year-old female is concerned about osteoporosis. The nurse
recommends which screening test as the gold standard for diagnosing this
condition?
A. Serum calcium level
B. DEXA scan (dual-energy X-ray absorptiometry)
C. Plain radiograph of the spine
D. 24-hour urine calcium
Answer: B.
Rationale: DEXA scan is the gold standard for measuring bone mineral
density and diagnosing osteoporosis. Serum calcium and urine calcium are
useful for metabolic workups but do not diagnose osteoporosis. Plain
radiographs only show bone loss after significant demineralization
, (usually >30%). The DEXA provides a T-score that guides treatment
decisions.
7. During a postpartum home visit, the nurse assesses a mother who gave
birth 48 hours ago. The mother reports feeling overwhelmed and tearful.
Which action is most appropriate?
A. Reassure the mother that this is normal and she just needs rest.
B. Assess for additional signs of postpartum depression, such as inability to
care for the baby.
C. Schedule an immediate psychiatric evaluation for severe depression.
D. Advise the mother to stop breastfeeding to reduce stress.
Answer: B.
Rationale: The "baby blues" occur within the first 2–5 days postpartum
and include mood swings, tearfulness, and overwhelm, but these
symptoms resolve spontaneously. However, the nurse must assess for
postpartum depression (PPD) which may present with persistent sadness,
inability to care for self or baby, or thoughts of harm. Option A is
dismissive; the nurse must differentiate. Option C is premature without
further assessment. Option D is not indicated and breastfeeding does not
cause PPD.
8. A 16-year-old male comes for a sports physical. The nurse counsels him
about injury prevention. Which recommendation is most important for this
adolescent?
A. Avoid all contact sports due to risk of concussion.
B. Use properly fitting protective gear and equipment.
C. Drink only water, not sports drinks.
D. Stretch only after exercise, not before.
Answer: B.
Rationale: Properly fitting protective equipment (helmets, pads,
mouthguards) is critical in preventing sports-related injuries, especially
concussions and fractures. Option A is unrealistic; adolescents can
participate in contact sports with appropriate precautions. Option C is
