NCLEX RN Health Promotion &
Maintenance Exam 2 Questions And
Correct Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
Download Pdf
1. Prenatal Vitamin Teaching
A nurse is teaching a client who is 8 weeks pregnant about prenatal
vitamins. The client asks why folic acid is so important. The nurse's best
response is that folic acid helps prevent:
A) Preterm labor
B) Neural tube defects
C) Gestational diabetes
D) Postpartum hemorrhage
Correct Answer: B
Rationale: Folic acid taken before conception and during early pregnancy
significantly reduces the risk of neural tube defects such as spina bifida. It does
not prevent preterm labor, gestational diabetes, or postpartum hemorrhage.
Adequate folic acid intake is critical during the first trimester when the neural
tube is closing.
2. Newborn Hearing Screening
The nurse reviews the results of a universal newborn hearing screening. The
test indicates a “refer” result in one ear. Which action should the nurse take
next?
,A) Repeat the screening immediately before discharge
B) Schedule diagnostic auditory brainstem response testing
C) Reassure the parents that the result is likely a false positive
D) Administer the first dose of the pneumococcal vaccine
Correct Answer: B
Rationale: A “refer” result on newborn hearing screening requires prompt
diagnostic evaluation with auditory brainstem response (ABR) testing. The initial
screen is a screening tool, not diagnostic; repeating it immediately is not
recommended. Reassuring the parents that it is a false positive is inappropriate
because the result could indicate hearing loss. Vaccination is unrelated and does
not replace follow-up.
3. Toddler Car Seat Safety
A parent of a 2-year-old who weighs 28 lb (12.7 kg) asks when the child can
face forward in a car seat. According to current best-practice guidelines, the
nurse should instruct the parent to keep the child rear-facing until at least:
A) Age 1 year
B) Age 2 years
C) Weight 20 lb
D) The maximum height or weight limit of the rear-facing seat
Correct Answer: D
Rationale: The American Academy of Pediatrics recommends that children
remain in a rear-facing car seat as long as possible, until they reach the highest
weight or height allowed by the seat’s manufacturer. This typically allows rear-
facing beyond age 2, providing optimal protection for the head, neck, and spine
in a crash. Age or weight alone are not sufficient criteria if the seat’s limits have
not been reached.
4. Fall Prevention in the Home
A home health nurse visits an 82-year-old client who uses a walker. Which
, finding poses the greatest risk for falls and should be addressed
immediately?
A) Scatter rugs on the kitchen floor
B) Grab bars installed near the toilet
C) A night-light in the hallway
D) A raised toilet seat
Correct Answer: A
Rationale: Scatter rugs are a major tripping hazard and should be removed or
secured with nonslip backing. Grab bars, night-lights, and raised toilet seats are
interventions that reduce fall risk. Loose rugs directly contradict home safety
recommendations and pose an immediate danger.
5. Immunization Schedule for a 4 Month Old
A 4-month-old infant is brought for a well-child visit. The baby has received
the first doses of DTaP, IPV, Hib, PCV13, and rotavirus vaccine at 2 months.
Which vaccines should the nurse anticipate administering today?
A) MMR and varicella
B) DTaP, IPV, Hib, PCV13, and rotavirus (second doses)
C) Hepatitis A and influenza (if in season)
D) Only the third dose of hepatitis B
Correct Answer: B
Rationale: At the 4-month visit, infants routinely receive the second doses of
DTaP, IPV, Hib, PCV13, and rotavirus. MMR and varicella are given at 12–15
months. Hepatitis A is given at 12 months and older. The third hepatitis B dose is
typically given at 6 months. Inactivated influenza vaccine can be given starting
at 6 months, not 4 months.
6. Self Breast Exam Teaching
The nurse teaches a 25-year-old client how to perform breast self-
, examination (BSE). Which statement by the client indicates a need for
further instruction?
A) “I will look at my breasts in the mirror with my arms at my sides and then
raised.”
B) “I should examine my breasts lying down with a pillow under my shoulder.”
C) “The best time for me to do BSE is right before my period starts.”
D) “I will use the pads of my three middle fingers to feel for lumps.”
Correct Answer: C
Rationale: Breast self-examination should be performed when the breasts are
least tender and lumpy, which is usually several days after the menstrual period
ends, not just before it. The other statements describe correct BSE technique:
visual inspection with arms in different positions, palpation while lying down
with a pillow, and using the finger pads.
7. Osteoporosis Prevention
A 55-year-old postmenopausal client asks about preventing osteoporosis.
Which recommendation should the nurse include?
A) Avoid all weight-bearing exercise to protect the spine
B) Take 1,500 mg of calcium daily through diet and supplements
C) Limit vitamin D intake to 200 IU per day
D) Drink at least three cups of caffeinated coffee daily
Correct Answer: B
Rationale: Postmenopausal women should consume 1,200 to 1,500 mg of
calcium daily (diet plus supplements if needed) to maintain bone density.
Weight-bearing exercise stimulates bone formation and should be encouraged,
not avoided. Vitamin D intake should be 800–1,000 IU daily or more, not limited
to 200 IU. High caffeine intake can promote calcium loss and should be limited.
Maintenance Exam 2 Questions And
Correct Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
Download Pdf
1. Prenatal Vitamin Teaching
A nurse is teaching a client who is 8 weeks pregnant about prenatal
vitamins. The client asks why folic acid is so important. The nurse's best
response is that folic acid helps prevent:
A) Preterm labor
B) Neural tube defects
C) Gestational diabetes
D) Postpartum hemorrhage
Correct Answer: B
Rationale: Folic acid taken before conception and during early pregnancy
significantly reduces the risk of neural tube defects such as spina bifida. It does
not prevent preterm labor, gestational diabetes, or postpartum hemorrhage.
Adequate folic acid intake is critical during the first trimester when the neural
tube is closing.
2. Newborn Hearing Screening
The nurse reviews the results of a universal newborn hearing screening. The
test indicates a “refer” result in one ear. Which action should the nurse take
next?
,A) Repeat the screening immediately before discharge
B) Schedule diagnostic auditory brainstem response testing
C) Reassure the parents that the result is likely a false positive
D) Administer the first dose of the pneumococcal vaccine
Correct Answer: B
Rationale: A “refer” result on newborn hearing screening requires prompt
diagnostic evaluation with auditory brainstem response (ABR) testing. The initial
screen is a screening tool, not diagnostic; repeating it immediately is not
recommended. Reassuring the parents that it is a false positive is inappropriate
because the result could indicate hearing loss. Vaccination is unrelated and does
not replace follow-up.
3. Toddler Car Seat Safety
A parent of a 2-year-old who weighs 28 lb (12.7 kg) asks when the child can
face forward in a car seat. According to current best-practice guidelines, the
nurse should instruct the parent to keep the child rear-facing until at least:
A) Age 1 year
B) Age 2 years
C) Weight 20 lb
D) The maximum height or weight limit of the rear-facing seat
Correct Answer: D
Rationale: The American Academy of Pediatrics recommends that children
remain in a rear-facing car seat as long as possible, until they reach the highest
weight or height allowed by the seat’s manufacturer. This typically allows rear-
facing beyond age 2, providing optimal protection for the head, neck, and spine
in a crash. Age or weight alone are not sufficient criteria if the seat’s limits have
not been reached.
4. Fall Prevention in the Home
A home health nurse visits an 82-year-old client who uses a walker. Which
, finding poses the greatest risk for falls and should be addressed
immediately?
A) Scatter rugs on the kitchen floor
B) Grab bars installed near the toilet
C) A night-light in the hallway
D) A raised toilet seat
Correct Answer: A
Rationale: Scatter rugs are a major tripping hazard and should be removed or
secured with nonslip backing. Grab bars, night-lights, and raised toilet seats are
interventions that reduce fall risk. Loose rugs directly contradict home safety
recommendations and pose an immediate danger.
5. Immunization Schedule for a 4 Month Old
A 4-month-old infant is brought for a well-child visit. The baby has received
the first doses of DTaP, IPV, Hib, PCV13, and rotavirus vaccine at 2 months.
Which vaccines should the nurse anticipate administering today?
A) MMR and varicella
B) DTaP, IPV, Hib, PCV13, and rotavirus (second doses)
C) Hepatitis A and influenza (if in season)
D) Only the third dose of hepatitis B
Correct Answer: B
Rationale: At the 4-month visit, infants routinely receive the second doses of
DTaP, IPV, Hib, PCV13, and rotavirus. MMR and varicella are given at 12–15
months. Hepatitis A is given at 12 months and older. The third hepatitis B dose is
typically given at 6 months. Inactivated influenza vaccine can be given starting
at 6 months, not 4 months.
6. Self Breast Exam Teaching
The nurse teaches a 25-year-old client how to perform breast self-
, examination (BSE). Which statement by the client indicates a need for
further instruction?
A) “I will look at my breasts in the mirror with my arms at my sides and then
raised.”
B) “I should examine my breasts lying down with a pillow under my shoulder.”
C) “The best time for me to do BSE is right before my period starts.”
D) “I will use the pads of my three middle fingers to feel for lumps.”
Correct Answer: C
Rationale: Breast self-examination should be performed when the breasts are
least tender and lumpy, which is usually several days after the menstrual period
ends, not just before it. The other statements describe correct BSE technique:
visual inspection with arms in different positions, palpation while lying down
with a pillow, and using the finger pads.
7. Osteoporosis Prevention
A 55-year-old postmenopausal client asks about preventing osteoporosis.
Which recommendation should the nurse include?
A) Avoid all weight-bearing exercise to protect the spine
B) Take 1,500 mg of calcium daily through diet and supplements
C) Limit vitamin D intake to 200 IU per day
D) Drink at least three cups of caffeinated coffee daily
Correct Answer: B
Rationale: Postmenopausal women should consume 1,200 to 1,500 mg of
calcium daily (diet plus supplements if needed) to maintain bone density.
Weight-bearing exercise stimulates bone formation and should be encouraged,
not avoided. Vitamin D intake should be 800–1,000 IU daily or more, not limited
to 200 IU. High caffeine intake can promote calcium loss and should be limited.
