NCLEX questions-Maternity (with rationales) Latest
Update 2023
A client who delivered by cesarean section 24 hours ago is using a patientcontrolled 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<\/p>\n\n\n\n
NCLEX questions-Maternity (with rationales) Latest
Update 2023
B. Trichomonas
C. Gonorrhea
D. Syphilis – correct answer \u2705C. 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 \u2705C. Rationale: The infant is becoming
frustrated and so is the mother; both need a time out. The mother should be<\/p>\n\n\n\n
NCLEX questions-Maternity (with rationales) Latest
Update 2023
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 \u2705A. 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?<\/p>\n\n\n\n
Maternity NCLEX Exam questions and Answers Latest
Update 2023
Prior to discharging a 24-hour-old newborn, the nurse assesses her
respiratory status. Which of the following would the nurse expect to assess?
A) Respiratory rate 45, irregular
B) Costal breathing pattern
C) Nasal flaring, rate 65
D) Crackles on auscultation – correct answer \u2705A
Typically, respirations in a 24-hour-old newborn are symmetric, slightly
irregular, shallow, and unlabored at a rate of 30 to 60 breaths\/minute. The
breathing pattern is primarily diaphragmatic. Nasal flaring, rates above 60
breaths per minute, and crackles suggest a problem.
The nurse encourages the mother of a healthy newborn to put the newborn
to the breast immediately after birth for which reason?
A) To aid in maturing the newborn’s sucking
reflex
B) To encourage the development of maternal antibodies
C) To facilitate maternal-infant bonding<\/p>\n\n\n\n
Maternity NCLEX Exam questions and Answers Latest
Update 2023
D) To enhance the clearing of the newborn’s respiratory passages – correct
answer \u2705C
Breast-feeding can be initiated immediately after birth. This immediate
mother-newborn contact takes advantage of the newborn’s natural alertness
and fosters bonding. This contact also reduces maternal bleeding and
stabilizes the newborn’s temperature, blood glucose level, and respiratory
rate. It is not associated with maturing the sucking reflex, encouraging the
development of maternal antibodies, or aiding in clearing of the newborn’s
respiratory passages.
When making a home visit, the nurse observes a newborn sleeping on his
back in a bassinet. In one corner of the bassinet is a soft stuffed animal and
at the other end is a bulb syringe. The nurse determines that the mother
needs additional teaching because of which of the following?
A) The newborn should not be sleeping on his back.
B) Stuffed animals should not be in areas where infants sleep.
C) The bulb syringe should not be kept in the bassinet.
D) This newborn should be sleeping in a crib. – correct answer \u2705B<\/p>\n\n\n\n
Maternity NCLEX Exam questions and Answers Latest
Update 2023
The nurse should instruct the mother to remove all fluffy bedding, quilts,
stuffed animals, and pillows from the crib to prevent suffocation. Newborns
and infants should be placed on their backs to sleep. Having the bulb syringe
nearby in the bassinet is appropriate. Although a crib is the safest sleeping
location, a bassinet is appropriate initially.
Assessment of a newborn reveals a heart rate of 180 beats\/minute. To
determine whether this finding is a common variation rather than a sign of
distress, what else does the nurse need to know?
A) How many hours old is this newborn?
B) How long ago did this newborn eat?
C) What was the newborn’s birthweight?
D) Is acrocyanosis present? – correct answer \u2705A
The typical heart rate of a newborn ranges from 120 to 160 beats per minute
with wide fluctuation during activity and sleep. Typically heart rate is
assessed every 30 minutes until stable for 2 hours after birth. The time of
the newborn’s last feeding and his birthweight would have no effect on his
heart rate. Acrocyanosis is a common normal finding in newborns.<\/p>\n\n\n\n
Maternity NCLEX Exam questions and Answers Latest
Update 2023
Just after delivery, a newborn’s axillary temperature is 94 degrees F. What
action would be most appropriate?
A) Assess the newborn’s gestational age.
B) Rewarm the newborn gradually.
C) Observe the newborn every hour.
D) Notify the physician if the temperature goes lower. – correct answer \u2705B
A newborn’s temperature is typically maintained at 36.5 to 37.5 degrees C
(97.7 to 99.7 degrees F). Since this newborn’s temperature is significantly
lower, the nurse should institute measures to rewarm the newborn
gradually. Assessment of gestational age is completed regardless of the
newborn’s temperature. Observation would be inappropriate because lack
of action may lead to a further lowering of the temperature. The nurse
should notify the physician of the newborn’s current temperature since it is
outside normal parameters.
The parents of a newborn become concerned when they notice that their
baby seems to stop breathing for a few seconds. After confirming the
parents’ findings by observing the newborn, which of the following actions
would be most appropriate?<\/p>\n\n\n\n
MATERNITY NCLEX Exam Questions and Answers Latest
2023
Which of the following maternal factors may decrease fetal oxygenation? Select all
that apply
A. Asthma
B. Gestational diabetes
C. Hypertension
D. Epidural – correct answer \u2705A. Asthma
C. Hypertension
D. Epidural
A 25 year old female is 25 weeks pregnant. she has had one previous pregnancy at
35 weeks and the baby is now 2 years old. she has no history of abortion – correct
answer \u2705G=2, T=0, P=1, A= 0, L=1
So I think the answer would be
G=2, T=0, P=1, A= 0, L=1
More complete description of pregnancy outcomesGTPALG-gravidaT-term>37
weeksP-preterm <37 weeksA-abortions (SAB or TAB)L- living children<\/p>\n\n\n\n
MATERNITY NCLEX Exam Questions and Answers Latest
2023
apart, 8 minutes apart and then 25 minutes. She is 2 cm dilated, her physician
would explain that she is in the \u2026. – correct answer \u27051st Stage, latent phase of
labor
Rationale:
1st stage: (latent) frequency 5-30 minutes, duration 30-40seconds, dilation 0-3cm
( active) frequency 3-5 minutes, duration 40-70 seconds, dilation 4-7cm
(transition) frequency 2-3 minutes, duration, 45-90 seconds, 10 cm dilated
Second stage: full dilation, progresses to contractions every 1-2 minutes
Third stage: delivery of the neonate
fourth stage: delivery of the placenta
Which of the following are maternal changes during pregnancy? (select all that
apply)
A. Decreased cardiac output
B. Increased clotting factors
C. Decreased lung volume
D. Skin color changes that should return to normal after pregnancy<\/p>\n\n\n\n
MATERNITY NCLEX Exam Questions and Answers Latest
2023
E. Supine hypertensive syndrome – correct answer \u2705Answers: B, C, D
A is incorrect because cardiac output increases with the 30% increased blood
volume to compensate for blood loss during birth and to provide fetus with
nutrient. E is incorrect because pregnant women develop supine hypotension
syndrome (vena caval syndrome), from baby putting pressure on the inferior vena
cava.
A pregnant woman who is in her late 3rd trimester called her primary care
provider complaining of contractions. Which of the following indicates that the
patient is experiencing true labor? Select all that apply.
A. My pain duration changes when I move around
B. My contractions are occurring every 6 minutes and last 1 minute long
C. I have pain located back to front
D. My cervix is changing
E. My contractions are coming 10, 7, and then 15 minutes apart – correct answer
\u2705Answer B,C,D
Rational: True labor is regular, location is back to front, and the duration remains
constant. Cervical change is a true indicator of labor.<\/p>\n\n\n\n
MATERNITY NCLEX Exam Questions and Answers Latest
2023
A pregnant women presents to her doctors office with nausea, vomiting, and
sharp abdominal pain. The doctor suspects an ectopic pregnancy. What would her
HCG levels look like?
HCG level slowly declining over 48 hours
HCG level rising but not doubling appropriately in 48 hours
HCG level drastically drops within 24 hours
No HCG hormone detected – correct answer \u2705Answer B
Rational: HCG levels would still rise because the fertilized ovum is still secreting
HCG even though it is in the wrong place. The HCG level would decline over 48
hours if their was a spontaneous abortion\/loss.
Janine is a 34-year-old female who is 36 weeks pregnant with fraternal twins, has
two living children that are also fraternal twins and now 4 years old, that she
delivered at 36 weeks via c-section. She had a therapeutic abortion at 23 years old
and spontaneously aborted during her second pregnancy at 27 years old. What is
her GTPAL?
A.) G=2, T=1, P=1, A=2, L=2
B.) G=4, T=1, P=0, A=2, L=2
C.) G=4, T=0, P=1, A=2, L=2
D.) G=4, T=0, P=1, A=1, L=2
E.) G=2, T=1, P=0, A=1, L=2 – correct answer \u2705Correct Answer: C<\/p>\n\n\n\n
Maternal\/Newborn Test 2 NCLEX Questions and
Answers New 2023!!!
Based on the hormonal theory of labor, the nurse anticipates a rise in which
of the following to begin a chain of hormonal events that cause labor?
A. Cortisol
B. Oxytocin
C. Progesterone
D. Estrogen – correct answer \u2705A. Cortisol
The nurse would recognize that the client has experienced lightening when
the pregnant woman reports:
A. “I can breath much better”
B. “My ankles are less swollen”
C. “I don’t have to urinate as often now”
D. “My lower back pain has been relieved” – correct answer \u2705A. “I can
breath much better”
Fetus has descended into pelvis, relieving pressure on diaphragm
The primary nurse performs a vaginal examination and finds a prolapsed
cord. The nurses priority action will be to:
A. Give medication to hasten a vaginal delivery<\/p>\n\n\n\n
Maternal\/Newborn Test 2 NCLEX Questions and
Answers New 2023!!!
B. Keep the client in a back-lying position
C. Make arrangements for an emergency cesarean section
D. Get the cord back to its original location – correct answer \u2705C. Make
arrangements for an emergency cesarean section
Position client to take pressure off cord while awaiting surgery
When the fetus is found to be in a vertex presentation, the nurse anticipates
the presenting fetal part will be the:
A. Forehead
B. Face
C. Buttocks
D. Occiput – correct answer \u2705D. Occiput
A nurse is caring for a client in labor who complains of feeling faint. The
nurse turns the client onto her side in order to have what effect on
contractions?
A. Little or no effect
B. Increase the frequency
C. Increase the intensity<\/p>\n\n\n\n
Maternal\/Newborn Test 2 NCLEX Questions and
Answers New 2023!!!
D. Stop the contractions – correct answer \u2705C. Increase the intensity
Also less frequent
The nurse recognizes that the client is in latent phase of the first stage of
Labor. This phase is best described as lasting from:
A. Undilated cervix to a 2cm dilation
B. Onset of contractions to 4cm
C. Cervix is dilated 4cm to dilation of 8cm
D. No contraction to contractions every 3 minutes – correct answer \u2705B.
Onset of contractions to 4cm
The nurse, working on a labor and delivery unit, anticipates active labor for a
primagravida will last how long?
A. 16-18h
B. 12-14h
C. 8-10h
D. 4-6h – correct answer \u2705D. 4-6h<\/p>\n\n\n\n
Maternal\/Newborn Test 2 NCLEX Questions and
Answers New 2023!!!
A client is in the transition phase of labor irritably tells the nurse not to
touch her. The nurses best action would be to:
A. Ask for someone else to support the client
B. Tell the client to be cooperative and do as you say
C. Remind the client to focus on relaxation and breathing
D. Ask the client to push actively with each contraction – correct answer \u2705C.
Remind the client to focus on relaxation and breathing
The student nurse asks the primary nurse to explain what the obstetrician
meant when telling the client that engagement has occurred. The primary
nurses best response would be to explain that:
A. The fetus has now become ballotable
B. The presenting part has entered the true pelvis
C. The presenting part is just above the Ischial spine
D. There is now observable crowning – correct answer \u2705B. The presenting
part has entered the true pelvis<\/p>\n\n\n\n
2023 Updated Maternity Exam 1 NCLEX Assured A+
A laboring woman is lying in the supine position. The most appropriate
nursing action is to:
a. Ask her to turn to one side.
b. Elevate her feet and legs.
c. Take her blood pressure.
d. Determine whether there is fetal tachycardia. – correct answer \u2705a. may
cause heavy uterus to put pressure on the vena cava. reducing blood to her
heart. relieved by having her turn to one side.
Which action best explains the main role of surfactant in the neonate?
A) Assists with ciliary body maturation in the upper airways
B) Helps maintain a rhythmic breathing pattern
C) Promotes clearing mucus from the respiratory tract
D) Helps the lungs remain expanded after the initiation of breathing – correct
answer \u2705D) Helps the lungs remain expanded after the initiation of
breathing<\/p>\n\n\n\n
2023 Updated Maternity Exam 1 NCLEX Assured A+
Surfactant works by reducing surface tension in the lung. Surfactant allows
the lung to remain slightly expanded, decreasing the amount of work
required for inspiration.
Four hours after a difficult labor and birth, a primiparous woman refuses to
feed her baby, stating that she is too tired and just wants to sleep. The nurse
should:
1.Tell the woman she can rest after she feeds her baby
2.Recognize this as a behavior of the taking-hold stage
3.Record the behavior as ineffective maternal-newborn attachment
4.Take the baby back to the nursery, reassuring the woman that her rest is a
priority at this time – correct answer \u27054. Response 1 does not take into
consideration the need for the new mother to be nurtured and have her
needs met during the taking-in stage. The behavior described is typical of
this stage and not a reflection of ineffective attachment unless the behavior
persists. Mothers need to reestablish their own well-being in order to
effectively care for their baby
Which anticipatory guidance action by the nurse makes role transition to
parenthood easier?<\/p>\n\n\n\n
2023 Updated Maternity Exam 1 NCLEX Assured A+
a. Helps the new parents identify resources
b. Recommends employing babysitters frequently
c. Tells the parents about the realities of parenthood
d. Offers a home phone number and tells parents to call if they have a
question – correct answer \u2705A
Available resources within the community can assist the parents in role
transition. Some parents may not be able to afford babysitters. Also, this
removes them from the parenthood role. Each adult sees parenthood in a
different light. They cannot be compared. Searching out resources for the
parents is an important task. However, the nurse should not give her
personal number to clients.
A client with group AB blood whose husband has group O has just given
birth. The major sign of ABO blood incompatibility in the neonate is which
complication or test result?
A) Negative Coombs test
B) Bleeding from the nose and ear<\/p>\n\n\n\n
2023 Updated Maternity Exam 1 NCLEX Assured A+
C) Jaundice after the first 24 hours of life
D) Jaundice within the first 24 hours of life – correct answer \u2705D
The neonate with ABO blood incompatibility with its mother will have
jaundice (pathologic) within the first 24 hours of life. The neonate would
have a positive Coombs test result
To promote bonding and attachment immediately after birth, which action
should the nurse take?
a. Assist the mother in feeding her baby.
b. Allow the mother quiet time with her infant.
c. Teach the mother about the concepts of bonding and attachment.
d. Assist the mother in assuming an en face position with her newborn. –
correct answer \u2705D
Assisting the mother in assuming an en face position with her newborn will
support the bonding process. After birth is a good time to initiate
breastfeeding, but first the mother needs time to explore the new infant and
begin the bonding process. The mother should be given as much privacy as<\/p>\n\n\n\n
Maternity NCLEX questions and Answers Latest Update
2023
What is the Kleihauer-Betke (“KB”) test and when is it used? – correct answer \u27051.
Used to measure the amount of fetal hemoglobin transferred from a fetus to a
mother’s bloodstream.<\/p>\n\n\n\n
Maternity NCLEX questions and Answers Latest Update
2023
d. trisomy 18
e. cystic fibrosis – correct answer \u2705b. multigestation
c. neural tube defects
A 24-hour urine collection is done for what reason in a pregnant woman? – correct
answer \u2705To check protein levels in pregnancy-induced hypertension
What is tested for in TORCH titer? – correct answer \u2705In TORCH titer,
toxoplasmosis, other (syphilis, parvovirus B19, and Varicella virus), rubella,
cytomegalovirus, and herpes simplex are tested for.
A positive contraction stress test involves what?
a. FHR acc-cells during contractions
b. FHR d-cells without contractions in 20 minutes
c. FHR acc-cells with contractions
d. FHR acc-cells without contractions in 20 minutes – correct answer \u2705A positive
CST is having fetal heart rate decelerations without contractions. This is also called
a “non-reassuring contraction stress test”.<\/p>\n","protected":false},"excerpt":{"rendered":"
NCLEX questions-Maternity (with rationales) LatestUpdate 2023A client who delivered by cesarean section 24 hours ago is using a patientcontrolled analgesia (PCA) pump for pain control. Her oral intake has beenice 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 tobreastfeed […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-117342","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/117342","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=117342"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/117342\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=117342"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=117342"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=117342"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}