Grade A+ NCLEX questions-Maternity (with rationales) 2025
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 C. Rationale: Impaired bowel motility caused by surgical anes-
nursing diagnosis has the highest priority? thesia, pain medication, and immobility (C) is the priority nursing
A. Altered nutrition, less than body requirements for lactation diagnosis and addresses the potential problem of a paralytic ileus.
B. Alteration in comfort related to nausea and abdominal disten- (A and B) are both caused by impaired bowel motility. (D) is not as
tion important as impaired motility.
C. Impaired bowel motility related to pain medication and immo-
bility
D.NFatigue related to cesarean delivery and physical care de-
mands of infant
The nurse is teaching care of the newborn to a childbirth prepa-
ration class and describes the need for administering antibiotic
ointment into the eyes of the newborn. An expectant father asks, C. Rationale: Erythromycin ointment is instilled into the lower con-
"What type of disease causes infections in babies that can be junctiva of each eye within 2 hours after birth to prevent ophthalmia
prevented by using this ointment?" Which response by the nurse neonatorum, an infection caused by gonorrhea (C), and inclusion
is accurate? conjunctivitis, an infection caused by Chlamydia. The infant may
A.NHerpes be exposed to these bacteria when passing through the birth
B. Trichomonas canal. Ophthalmic ointment is not effective against (A, B, or D).
C. Gonorrhea
D. Syphilis
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? C. Rationale: The infant is becoming frustrated and so is the
A. Encourage frequent use of a pacifier so that the infant becomes mother; both need a time out. The mother should be encouraged
accustomed to sucking. to comfort the infant and to relax herself (C). After such a time
B. Hold the infant's head firmly against the breast until he latches out, breastfeeding is often more successful. (A and D) would
onto the nipple. cause nipple confusion. (B) would only cause the infant to be
C. Encourage the mother to stop feeding for a few minutes and more resistant, resulting in the mother and infant to become more
comfort the infant. frustrated.
D. Provide formula for the infant until he becomes calm, and then
offer the breast again.
The nurse is counseling a couple who has sought information
about conceiving. The couple asks the nurse to explain when A. Rationale: Ovulation occurs 14 days before the first day of the
ovulation usually occurs. Which statement by the nurse is correct? menstrual period (A). Although ovulation can occur in the middle
A. Two weeks before menstruation of the cycle or 2 weeks after menstruation, this is only true for
B. Immediately after menstruation a woman who has a perfect 28-day cycle. For many women, the
C. Immediately before menstruation length of the menstrual cycle varies. (B, C, and D) are incorrect.
D. Three weeks before menstruation
The nurse instructs a laboring client to use accelerated blow
C. Rationale: Tingling fingers and dizziness are signs of hyper-
breathing. The client begins to complain of tingling fingers and
ventilation (blowing off too much carbon dioxide). Hyperventilation
dizziness. Which action should the nurse take?
is treated by retaining carbon dioxide. This can be facilitated by
A. Administer oxygen by face mask.
breathing into a paper bag or cupped hands (C). (A) is inappropri-
B. Notify the health care provider of the client's symptoms.
ate because the carbon dioxide level is low, not the oxygen level.
C. Have the client breathe into her cupped hands.
(B and D) are not specific for this situation.
D. Check the client's blood pressure and fetal heart rate.
D. Rationale: Learning is facilitated by an interested pupil. The
When assessing a client at 12 weeks of gestation, the nurse rec- couple is most interested in childbirth toward the end of the preg-
nancy, when they are beginning to anticipate the onset of labor and
ommends that she and her husband consider attending childbirth
preparation classes. When is the best time for the couple to attend 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
these classes?
during a pregnancy for the couple to attend childbirth education
A. At 16 weeks of gestation
classes. At these times they will have other teaching needs. Early
B. At 20 weeks of gestation
C. At 24 weeks of gestation pregnancy classes often include topics such as nutrition, physio-
logic changes, coping with normal discomforts of pregnancy, fetal
D. At 30 weeks of gestation
development, maternal and fetal risk factors, and evolving roles of
the mother and her significant others.
1/5
, Grade A+ NCLEX questions-Maternity (with rationales) 2025
One hour following a normal vaginal delivery, a newborn infant
boy's axillary temperature is 96° F, his lower lip is shaking and, D. Rationale: This infant is demonstrating signs of hypoglycemia,
when the nurse assesses for a Moro reflex, the boy's hands shake. possibly secondary to a low body temperature. The nurse should
Which intervention should the nurse implement first? first determine the serum glucose level (D). (A) is an intervention
A. Stimulate the infant to cry. for a lethargic infant. (B) should be done based on the temperature,
B. Wrap the infant in warm blankets. but first the glucose level should be obtained. (C) helps raise the
C. Feed the infant formula. blood sugar, but first the nurse should determine the glucose level.
D. Obtain a serum 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 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 my period." ovulation and menses, but is not completely effective as a birth
B. "Breastfeeding my baby immediately after drinking alcohol is control method (A). (B) is incorrect because alcohol can immedi-
safer than waiting for the alcohol to clear my breast milk. "
C. "I can start smoking cigarettes while breastfeeding because it ately enter the breast milk. Nicotine is transferred to the infant in
breast milk (C). Taking a warm shower will stimulate the production
will not affect my breast milk. "
of milk, which will be more painful after breastfeedings (D).
D. "When I take a warm shower after I breastfeed, it relieves the
pain from being engorged between breastfeedings. "
A client at 30 weeks of gestation is on bed rest at home because
of increased blood pressure. The home health nurse has taught
her how to take her own blood pressure and gave her parameters C.Rationale: Checking the blood pressure for an elevation (C) is
to judge a significant increase in blood pressure. When the client the best instruction to give at this time. A blood pressure exceeding
calls the clinic complaining of indigestion, which instruction should 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can
the nurse provide? be a sign of an impending seizure (eclampsia), a life-threaten-
A. Lie on your left side and call 911 for emergency assistance. ing complication of gestational hypertension. Additional data are
B. Take an antacid and call back if the pain has not subsided. needed to confirm an emergency situation as described in (A).
C. Take your blood pressure now and if it is seriously elevated, go (B and D) ignore the threat to client safety posed by a significant
to the hospital. increase in blood pressure.
D. See your health care provider to obtain a prescription for a
histamine blocking agent.
The nurse observes that an antepartum client who is on bed rest D. Rationale: The health care provider should be notified (D) when
for preterm labor is eating ice rather than the food on her breakfast a client practices pica (craving for and consumption of nonfood
tray. The client states that she has a craving for ice and then feels substances). The practice of pica may displace more nutritious
too full to eat anything else. Which is the best response by the foods from the diet, and the client should be evaluated for anemia.
nurse? (A) is overreacting and may be perceived as punishment by the
A. Remove all ice from the client's room. patient. (B) allows the dietary department to customize the client's
B. Ask the client what foods she might consider eating. tray but fails to address physiologic problems associated with not
C. Remind the client that what she eats affects her baby. consuming nutritious foods in pregnancy. (C) is judgmental and
D. Notify the health care provider. blocks further communication.
Which finding(s) is (are) of most concern to the nurse when caring A,C,E Rationale: (A and C) are signs of a possible miscarriage.
for a woman in the first trimester of pregnancy? (Select all that
Cramping with bright red bleeding is a sign that the client's men-
apply.)
strual cycle is about to begin. A decrease of tenderness in the
A. Cramping with bright red spotting
breast is a sign that hormone levels have declined and that a mis-
B. Extreme tenderness of the breast
carriage is imminent. (E) could be a sign of an ectopic pregnancy,
C. Lack of tenderness of the breast
which could be fatal if not discovered in time before rupture. (B and
D. Increased amounts of discharge
D) are normal signs during the first trimester of a pregnancy.
E. Increased right-side flank pain
Prior to discharge, what instructions should the nurse give to
parents regarding the newborn's umbilical cord care at home? C. Rationale: Recent studies have indicated that air drying or plain
A. Wash the cord frequently with mild soap and water. water application may be equal to or more effective than alcohol in
B. Cover the cord with a sterile dressing. the cord healing process (C). (A, B, and D) are incorrect because
C. Allow the cord to air-dry as much as possible. they promote moisture and increase the potential for infection.
D. Apply baby lotion after the baby's daily bath.
The nurse is evaluating a full-term multigravida who was induced
3 hours ago. The nurse determines that the client is dilated 7 cm
D. Rationale: The fetal heart rate indicates early decelerations,
and is 100% effaced at 0 station, with intact membranes. The
which are not an ominous sign, so the nurse should continue
monitor indicates that the FHR decelerates at the onset of several
to monitor the labor progress (D) and document the findings in
contractions and returns to baseline before each contraction ends.
the client's record. There is no reason to reapply the external
Which action should the nurse take?
A. Reapply the external transducer.
2/5
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 C. Rationale: Impaired bowel motility caused by surgical anes-
nursing diagnosis has the highest priority? thesia, pain medication, and immobility (C) is the priority nursing
A. Altered nutrition, less than body requirements for lactation diagnosis and addresses the potential problem of a paralytic ileus.
B. Alteration in comfort related to nausea and abdominal disten- (A and B) are both caused by impaired bowel motility. (D) is not as
tion important as impaired motility.
C. Impaired bowel motility related to pain medication and immo-
bility
D.NFatigue related to cesarean delivery and physical care de-
mands of infant
The nurse is teaching care of the newborn to a childbirth prepa-
ration class and describes the need for administering antibiotic
ointment into the eyes of the newborn. An expectant father asks, C. Rationale: Erythromycin ointment is instilled into the lower con-
"What type of disease causes infections in babies that can be junctiva of each eye within 2 hours after birth to prevent ophthalmia
prevented by using this ointment?" Which response by the nurse neonatorum, an infection caused by gonorrhea (C), and inclusion
is accurate? conjunctivitis, an infection caused by Chlamydia. The infant may
A.NHerpes be exposed to these bacteria when passing through the birth
B. Trichomonas canal. Ophthalmic ointment is not effective against (A, B, or D).
C. Gonorrhea
D. Syphilis
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? C. Rationale: The infant is becoming frustrated and so is the
A. Encourage frequent use of a pacifier so that the infant becomes mother; both need a time out. The mother should be encouraged
accustomed to sucking. to comfort the infant and to relax herself (C). After such a time
B. Hold the infant's head firmly against the breast until he latches out, breastfeeding is often more successful. (A and D) would
onto the nipple. cause nipple confusion. (B) would only cause the infant to be
C. Encourage the mother to stop feeding for a few minutes and more resistant, resulting in the mother and infant to become more
comfort the infant. frustrated.
D. Provide formula for the infant until he becomes calm, and then
offer the breast again.
The nurse is counseling a couple who has sought information
about conceiving. The couple asks the nurse to explain when A. Rationale: Ovulation occurs 14 days before the first day of the
ovulation usually occurs. Which statement by the nurse is correct? menstrual period (A). Although ovulation can occur in the middle
A. Two weeks before menstruation of the cycle or 2 weeks after menstruation, this is only true for
B. Immediately after menstruation a woman who has a perfect 28-day cycle. For many women, the
C. Immediately before menstruation length of the menstrual cycle varies. (B, C, and D) are incorrect.
D. Three weeks before menstruation
The nurse instructs a laboring client to use accelerated blow
C. Rationale: Tingling fingers and dizziness are signs of hyper-
breathing. The client begins to complain of tingling fingers and
ventilation (blowing off too much carbon dioxide). Hyperventilation
dizziness. Which action should the nurse take?
is treated by retaining carbon dioxide. This can be facilitated by
A. Administer oxygen by face mask.
breathing into a paper bag or cupped hands (C). (A) is inappropri-
B. Notify the health care provider of the client's symptoms.
ate because the carbon dioxide level is low, not the oxygen level.
C. Have the client breathe into her cupped hands.
(B and D) are not specific for this situation.
D. Check the client's blood pressure and fetal heart rate.
D. Rationale: Learning is facilitated by an interested pupil. The
When assessing a client at 12 weeks of gestation, the nurse rec- couple is most interested in childbirth toward the end of the preg-
nancy, when they are beginning to anticipate the onset of labor and
ommends that she and her husband consider attending childbirth
preparation classes. When is the best time for the couple to attend 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
these classes?
during a pregnancy for the couple to attend childbirth education
A. At 16 weeks of gestation
classes. At these times they will have other teaching needs. Early
B. At 20 weeks of gestation
C. At 24 weeks of gestation pregnancy classes often include topics such as nutrition, physio-
logic changes, coping with normal discomforts of pregnancy, fetal
D. At 30 weeks of gestation
development, maternal and fetal risk factors, and evolving roles of
the mother and her significant others.
1/5
, Grade A+ NCLEX questions-Maternity (with rationales) 2025
One hour following a normal vaginal delivery, a newborn infant
boy's axillary temperature is 96° F, his lower lip is shaking and, D. Rationale: This infant is demonstrating signs of hypoglycemia,
when the nurse assesses for a Moro reflex, the boy's hands shake. possibly secondary to a low body temperature. The nurse should
Which intervention should the nurse implement first? first determine the serum glucose level (D). (A) is an intervention
A. Stimulate the infant to cry. for a lethargic infant. (B) should be done based on the temperature,
B. Wrap the infant in warm blankets. but first the glucose level should be obtained. (C) helps raise the
C. Feed the infant formula. blood sugar, but first the nurse should determine the glucose level.
D. Obtain a serum 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 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 my period." ovulation and menses, but is not completely effective as a birth
B. "Breastfeeding my baby immediately after drinking alcohol is control method (A). (B) is incorrect because alcohol can immedi-
safer than waiting for the alcohol to clear my breast milk. "
C. "I can start smoking cigarettes while breastfeeding because it ately enter the breast milk. Nicotine is transferred to the infant in
breast milk (C). Taking a warm shower will stimulate the production
will not affect my breast milk. "
of milk, which will be more painful after breastfeedings (D).
D. "When I take a warm shower after I breastfeed, it relieves the
pain from being engorged between breastfeedings. "
A client at 30 weeks of gestation is on bed rest at home because
of increased blood pressure. The home health nurse has taught
her how to take her own blood pressure and gave her parameters C.Rationale: Checking the blood pressure for an elevation (C) is
to judge a significant increase in blood pressure. When the client the best instruction to give at this time. A blood pressure exceeding
calls the clinic complaining of indigestion, which instruction should 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can
the nurse provide? be a sign of an impending seizure (eclampsia), a life-threaten-
A. Lie on your left side and call 911 for emergency assistance. ing complication of gestational hypertension. Additional data are
B. Take an antacid and call back if the pain has not subsided. needed to confirm an emergency situation as described in (A).
C. Take your blood pressure now and if it is seriously elevated, go (B and D) ignore the threat to client safety posed by a significant
to the hospital. increase in blood pressure.
D. See your health care provider to obtain a prescription for a
histamine blocking agent.
The nurse observes that an antepartum client who is on bed rest D. Rationale: The health care provider should be notified (D) when
for preterm labor is eating ice rather than the food on her breakfast a client practices pica (craving for and consumption of nonfood
tray. The client states that she has a craving for ice and then feels substances). The practice of pica may displace more nutritious
too full to eat anything else. Which is the best response by the foods from the diet, and the client should be evaluated for anemia.
nurse? (A) is overreacting and may be perceived as punishment by the
A. Remove all ice from the client's room. patient. (B) allows the dietary department to customize the client's
B. Ask the client what foods she might consider eating. tray but fails to address physiologic problems associated with not
C. Remind the client that what she eats affects her baby. consuming nutritious foods in pregnancy. (C) is judgmental and
D. Notify the health care provider. blocks further communication.
Which finding(s) is (are) of most concern to the nurse when caring A,C,E Rationale: (A and C) are signs of a possible miscarriage.
for a woman in the first trimester of pregnancy? (Select all that
Cramping with bright red bleeding is a sign that the client's men-
apply.)
strual cycle is about to begin. A decrease of tenderness in the
A. Cramping with bright red spotting
breast is a sign that hormone levels have declined and that a mis-
B. Extreme tenderness of the breast
carriage is imminent. (E) could be a sign of an ectopic pregnancy,
C. Lack of tenderness of the breast
which could be fatal if not discovered in time before rupture. (B and
D. Increased amounts of discharge
D) are normal signs during the first trimester of a pregnancy.
E. Increased right-side flank pain
Prior to discharge, what instructions should the nurse give to
parents regarding the newborn's umbilical cord care at home? C. Rationale: Recent studies have indicated that air drying or plain
A. Wash the cord frequently with mild soap and water. water application may be equal to or more effective than alcohol in
B. Cover the cord with a sterile dressing. the cord healing process (C). (A, B, and D) are incorrect because
C. Allow the cord to air-dry as much as possible. they promote moisture and increase the potential for infection.
D. Apply baby lotion after the baby's daily bath.
The nurse is evaluating a full-term multigravida who was induced
3 hours ago. The nurse determines that the client is dilated 7 cm
D. Rationale: The fetal heart rate indicates early decelerations,
and is 100% effaced at 0 station, with intact membranes. The
which are not an ominous sign, so the nurse should continue
monitor indicates that the FHR decelerates at the onset of several
to monitor the labor progress (D) and document the findings in
contractions and returns to baseline before each contraction ends.
the client's record. There is no reason to reapply the external
Which action should the nurse take?
A. Reapply the external transducer.
2/5
