1 Exampromax - Stuvia US 2025/2026
NCLEX questions-Maternity (with rationales) Questions
and Correct Detailed Answers (Verified Answers)
||Already Graded A+||Newest Version
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
Exampromax - Stuvia US
infant
Approved By:
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.
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
, 2 Exampromax - Stuvia US 2025/2026
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).
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.
Exampromax - Stuvia US
C. Encourage the mother to stop feeding for a few minutes and comfort the
infant.
Approved By:
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.
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
NCLEX questions-Maternity (with rationales) Questions
and Correct Detailed Answers (Verified Answers)
||Already Graded A+||Newest Version
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
Exampromax - Stuvia US
infant
Approved By:
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.
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
, 2 Exampromax - Stuvia US 2025/2026
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).
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.
Exampromax - Stuvia US
C. Encourage the mother to stop feeding for a few minutes and comfort the
infant.
Approved By:
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.
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
