NCLEX questions-Maternity (with rationales)
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 Correct Answer: 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.
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 Correct Answer: 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).
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. Correct
Answer: 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.
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 Correct Answer: 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.
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. Correct Answer: C. Rationale: Tingling fingers
and dizziness 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.
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 Correct Answer: D. Rationale: Learning is facilitated by an interested pupil.
The couple is most interested in childbirth toward the end of the pregnancy, when they are beginning to
anticipate the onset of labor and 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 during a pregnancy for the couple to
attend childbirth education classes. At these times they will have other teaching needs. Early pregnancy
classes often include topics such as nutrition, physiologic changes, coping with normal discomforts of
pregnancy, fetal development, maternal and fetal risk factors, and evolving roles of the mother and her
significant others.
One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his
lower lip is shaking and, when the nurse assesses for a Moro reflex, the boy's hands shake. Which
intervention should the nurse implement first?
A. Stimulate the infant to cry.
B. Wrap the infant in warm blankets.
C. Feed the infant formula.
D. Obtain a serum glucose level. Correct Answer: D. Rationale: This infant is demonstrating signs of
hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the
serum glucose level (D). (A) is an intervention for a lethargic infant. (B) should be done based on the
temperature, but first the glucose level should be obtained. (C) helps raise the blood sugar, but first the
nurse should determine the glucose level.
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 Correct Answer: 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.
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 Correct Answer: 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).
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. Correct
Answer: 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.
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 Correct Answer: 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.
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. Correct Answer: C. Rationale: Tingling fingers
and dizziness 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.
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 Correct Answer: D. Rationale: Learning is facilitated by an interested pupil.
The couple is most interested in childbirth toward the end of the pregnancy, when they are beginning to
anticipate the onset of labor and 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 during a pregnancy for the couple to
attend childbirth education classes. At these times they will have other teaching needs. Early pregnancy
classes often include topics such as nutrition, physiologic changes, coping with normal discomforts of
pregnancy, fetal development, maternal and fetal risk factors, and evolving roles of the mother and her
significant others.
One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his
lower lip is shaking and, when the nurse assesses for a Moro reflex, the boy's hands shake. Which
intervention should the nurse implement first?
A. Stimulate the infant to cry.
B. Wrap the infant in warm blankets.
C. Feed the infant formula.
D. Obtain a serum glucose level. Correct Answer: D. Rationale: This infant is demonstrating signs of
hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the
serum glucose level (D). (A) is an intervention for a lethargic infant. (B) should be done based on the
temperature, but first the glucose level should be obtained. (C) helps raise the blood sugar, but first the
nurse should determine the glucose level.
