Maternal Child NCLEX Review Questions
and 100% verified answers updated version
2025/2026 (passing score guarantee)
A nurse is assessing a premature infant. What would initially alert the nurse that the infant is having
respiratory distress?
A. Flaring nostrils
B. Sporadic crying
C. Ineffective cough
D. Decreased pulse rate - Answer Answer: A
Rationale:
In attempt to increase intake of oxygen, the respiratory rate increases with flaring of nostrils as a
cardinal sign. It is significant to note that when a neonate is in respiratory distress, the rate of
respirations will increase. Sporadic crying, ineffective cough, and decreased pulse rate may be indicative
of infant distress but are not classic signs of respiratory distress.
A newborn infant is diagnosed with a patent ductus arteriosus (PDA). The nurse is aware that this is
indicative of a defect that:
A. typically results in cyanosis
B. may result in congestive heart failure
C. also causes pulmonary stenosis
D. normally does not close after birth - Answer Answer: B
Rationale:
Defects that result in increased pulmonary blood flow such as patent ductus arteriosus (PDA) and other
atrial and ventricular septal defects may cause congestive heart failure. PDA is a vascular connection
that during fetal life bypasses the pulmonary vascular bed and directs blood from the pulmonary artery
to the aorta. Defects that involve decreased pulmonary blood (such as tetralogy of Fallot) or obstruction
to blood flow out of the heart (such as pulmonary stenosis) typically result in cyanosis. PDA does not
cause pulmonary stenosis. A PDA normally closes soon after birth. If the ductus does remain open after
, birth, the direction of blood flow in the ductus is reversed by the higher pressure in the aorta, so there
may not be any signs of the disorder.
Which of the following signs would alert a nurse to withdrawal in the infant of a mother addicted to
heroin?
A. lethargy and a lack of appetite
B. restlessness, irritability, and tremors
C. no crying and hypoactive reflexes
D. hyperactive reflexes and diaphoresis - Answer Answer: B
Rationale:
Heroin does cross the placental barrier; therefore the infant is born addicted to heroin and will display
signs of withdrawal such as restlessness, irritability, and tremors. The items listed in answer options A, C,
and D are not associated with heroin withdrawal.
A neonate weights 8 lb, 1 oz at birth. At age 3 days, the weight has decreased to 7 lb, 12 oz. The nurse
should instruct the mother to:
A. increase the amount of formula to prevent further dehydration and weight loss
B. continue feeding on demand because the noted weight loss is within normal limits
C. give additional feedings because the weight loss indicates inadequate caloric intake
D. switch to a different formula because the current one is inadequate to maintain weight - Answer
Answer: B
Rationale:
Neonates tend to lose 5% -- 10% of their birth weight during the first few days after birth, mostly
because of decreased, but acceptable, nutrition and extracellular fluid loss. Increasing formula volumes
and feedings or changing the formula is not necessary in this situation.
A nurse explains to a new mother reasons for her newborn's cranial molding and determines that the
mother needs further instruction when she makes which of the following statements?
and 100% verified answers updated version
2025/2026 (passing score guarantee)
A nurse is assessing a premature infant. What would initially alert the nurse that the infant is having
respiratory distress?
A. Flaring nostrils
B. Sporadic crying
C. Ineffective cough
D. Decreased pulse rate - Answer Answer: A
Rationale:
In attempt to increase intake of oxygen, the respiratory rate increases with flaring of nostrils as a
cardinal sign. It is significant to note that when a neonate is in respiratory distress, the rate of
respirations will increase. Sporadic crying, ineffective cough, and decreased pulse rate may be indicative
of infant distress but are not classic signs of respiratory distress.
A newborn infant is diagnosed with a patent ductus arteriosus (PDA). The nurse is aware that this is
indicative of a defect that:
A. typically results in cyanosis
B. may result in congestive heart failure
C. also causes pulmonary stenosis
D. normally does not close after birth - Answer Answer: B
Rationale:
Defects that result in increased pulmonary blood flow such as patent ductus arteriosus (PDA) and other
atrial and ventricular septal defects may cause congestive heart failure. PDA is a vascular connection
that during fetal life bypasses the pulmonary vascular bed and directs blood from the pulmonary artery
to the aorta. Defects that involve decreased pulmonary blood (such as tetralogy of Fallot) or obstruction
to blood flow out of the heart (such as pulmonary stenosis) typically result in cyanosis. PDA does not
cause pulmonary stenosis. A PDA normally closes soon after birth. If the ductus does remain open after
, birth, the direction of blood flow in the ductus is reversed by the higher pressure in the aorta, so there
may not be any signs of the disorder.
Which of the following signs would alert a nurse to withdrawal in the infant of a mother addicted to
heroin?
A. lethargy and a lack of appetite
B. restlessness, irritability, and tremors
C. no crying and hypoactive reflexes
D. hyperactive reflexes and diaphoresis - Answer Answer: B
Rationale:
Heroin does cross the placental barrier; therefore the infant is born addicted to heroin and will display
signs of withdrawal such as restlessness, irritability, and tremors. The items listed in answer options A, C,
and D are not associated with heroin withdrawal.
A neonate weights 8 lb, 1 oz at birth. At age 3 days, the weight has decreased to 7 lb, 12 oz. The nurse
should instruct the mother to:
A. increase the amount of formula to prevent further dehydration and weight loss
B. continue feeding on demand because the noted weight loss is within normal limits
C. give additional feedings because the weight loss indicates inadequate caloric intake
D. switch to a different formula because the current one is inadequate to maintain weight - Answer
Answer: B
Rationale:
Neonates tend to lose 5% -- 10% of their birth weight during the first few days after birth, mostly
because of decreased, but acceptable, nutrition and extracellular fluid loss. Increasing formula volumes
and feedings or changing the formula is not necessary in this situation.
A nurse explains to a new mother reasons for her newborn's cranial molding and determines that the
mother needs further instruction when she makes which of the following statements?
