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 becau...
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 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 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.
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. 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 Ans- 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. Ans- 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 Ans- 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
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