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NCLEX NCLEX-RN Exam
National Council Licensure Examination - NCLEX-RN (Page 68 )

Updated On: 25-Jan-2026
Page 68 of 345
PDF with 862 Questions

A mother continues to breast-feed her 3-month-old infant. She tells the nurse that over the past 3 days she has not been producing enough milk to satisfy the infant. The nurse advises the mother to do which of the following?

  1. "Start the child on solid food."
  2. "Nurse the child more frequently during this growth spurt."
  3. "Provide supplements for the child between breastfeeding so you will have enough milk."
  4. "Wait 4 hours between feedings so that your breasts will fill up."

Answer(s): B

Explanation:

(A) Solid foods introduced before 4­6 months of age are not compatible with the abilities of the GI tract and the nutritional needs of the infant. (B) Production of milk is supply and demand. A common growth spurt occurs at 3 months of age, and more frequent nursing will increase the milk supply to satisfy the infant. (C) Supplementation will decrease the infant's appetite and in turn decrease the milk supply. When the infant nurses less often or with less vigor, the amount of milk produced decreases. (D) Rigid feeding schedules lead to a decreased milk supply, whereas frequent nursing signals the mother's body to produce a correspondingly increased amount of milk.



In assessing the nature of the stool of a client who has cystic fibrosis, what would the nurse expect to see?

  1. Clay-colored stools
  2. Steatorrhea stools
  3. Dark brown stools
  4. Blood-tinged stools

Answer(s): B

Explanation:

(A) Clay-colored stools indicate dysfunction of the liver or biliary tract. (B) In the early stages of cystic fibrosis, fat absorption is primarily affected resulting in fat, foul, frothy, bulky stools. (C) Dark brown stools indicate normal passage through the colon. (D) Blood-tinged stools indicate dysfunction of the gastrointestinal (GI) tract.



A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full-term girl and is now progressing toward the establishment of successful lactation. To remove the baby from her breast, she should be instructed to:

  1. Gently pull the infant away
  2. Withdraw the breast from the infant's mouth
  3. Compress the areolar tissue until the infant drops the nipple from her mouth
  4. Insert a clean finger into the baby's mouth beside the nipple

Answer(s): D

Explanation:

(A) In pulling the infant away from the breast without breaking suction, nipple trauma is likely to occur. (B) In pulling the breast away from the infant without breaking suction, nipple trauma is likely to occur. (C) Compressing the maternal tissue does not break the suction of the infant on the breast and can cause nipple trauma. (D) By inserting a finger into the infant's mouth beside the nipple, the lactating mother can break the suction and the nipple can be removed without trauma.



The nurse provides a male client with diet teaching so that he can help prevent constipation in the future. Which food choices indicate that this teaching has been understood?

  1. Omelette and hash browns
  2. Pancakes and syrup
  3. Bagel with cream cheese
  4. Cooked oatmeal and grapefruit half

Answer(s): D

Explanation:

(A) Eggs and hash browns do not provide much fiber and bulk, so they do not effectively prevent constipation. (B) Pancakes and syrup also have little fiber and bulk, so they do not effectively prevent constipation. (C) Bagel and cream cheese do not provide intestinal bulk. (D) A combination of oatmeal and fresh fruit will provide fiber and intestinal bulk.



The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?

  1. Pulse rate of 50­70 bpm by her third postpartum day
  2. Diuresis by her second or third postpartum day
  3. Vaginal discharge or rubra, serosa, then rubra
  4. Diaphoresis by her third postpartum day

Answer(s): C

Explanation:

(A) Bradycardia is an expected assessment during the postpartum period. (B) Diuresis can occur during labor and the postpartum period and is an expected physiological adaptation. (C) A return of rubra after the serosa period may indicate a postpartal complication. (D) Diaphoresis, especially at night, is an expected physiological change and does not indicate an infectious process. Bradycardia, diuresis, and diaphoresis are normal postpartum physiological responses to adjust the cardiac output and blood volume to the nonpregnant state.



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