NCLEX Health Promotion and Maintenance Practice Test
What is in this test
| Topic | Focus | Items |
|---|---|---|
| Growth and Development | Milestones, play and age-appropriate teaching | 5 |
| Postpartum and Newborn Care | BUBBLE-HE, haemorrhage and newborn transition | 4 |
| Antepartum Care | Prenatal assessment, danger signs and teaching | 4 |
| Labour and Birth | Stages, fetal monitoring and complications | 3 |
| Screening and Disease Prevention | Immunisations, screening intervals and lifestyle teaching | 2 |
| The Aging Adult | Normal aging versus pathology | 2 |
Item formats in this test: Multiple choice, Select all that apply, Ordered response. This is test 3 of 9 — there is one for every client-need category.
The 20 questions
A parent asks when their infant should be able to sit with support and transfer objects from hand to hand. Which age should the nurse identify?
Show answer and rationale
Correct answer: C. Six months
By about six months an infant can sit with support, transfer objects between hands, roll in both directions and begin teething.
Why the other options are wrong
- A. At two months the milestone is the social smile and lifting the head briefly when prone.
- B. At four months the infant rolls front to back and holds the head steady.
- D. By twelve months the infant pulls to stand, may take first steps and says one to three words.
Which injury prevention teaching is most important for the parent of a 2-year-old?
Show answer and rationale
Correct answer: A. Store cleaning products in a locked cupboard and never leave the child alone near water
Toddlers have new mobility, no risk awareness and a habit of putting things in their mouths. Poisoning and drowning are the leading preventable causes of injury at this age.
Why the other options are wrong
- B. Independent swimming is a preschool and school-age skill; a toddler still needs constant supervision.
- C. Driving safety is relevant to adolescents.
- D. Bicycle safety becomes relevant in the school-age years.
A breastfeeding mother asks how she will know her 5-day-old newborn is getting enough milk. Which response by the nurse is best?
Show answer and rationale
Correct answer: B. "Six or more wet nappies a day and steady weight gain are the best signs."
Output and weight are the objective markers of adequate intake. From about day four, six or more wet nappies daily with appropriate weight gain confirms the newborn is feeding well.
Why the other options are wrong
- A. Long sleep stretches in a newborn can indicate poor intake and dehydration rather than satisfaction.
- C. Breasts are never completely empty, and this is not a measure of infant intake.
- D. Routine supplementation reduces milk supply by decreasing stimulation.
A nurse is counselling a client planning pregnancy. Which supplement most reduces the risk of neural tube defects?
Show answer and rationale
Correct answer: B. Folic acid
Folic acid taken before conception and in early pregnancy substantially reduces neural tube defects, because the neural tube closes in the first four weeks, often before pregnancy is recognised.
Why the other options are wrong
- A. Vitamin C supports iron absorption and healing but has no established role in neural tube defect prevention.
- C. Calcium supports fetal skeletal development.
- D. Vitamin E is an antioxidant with no established preventive role here.
Two hours after a vaginal birth, the nurse finds the fundus boggy and displaced to the right of the umbilicus, with heavy lochia. Which action should the nurse take first?
Show answer and rationale
Correct answer: A. Massage the fundus
A boggy uterus is not contracting, and massage is the immediate mechanical action that stimulates contraction and slows bleeding. It takes seconds and requires no order.
Why the other options are wrong
- B. Emptying the bladder addresses the displacement and is the next step, but massage stops the bleeding sooner.
- C. A uterotonic is given if massage and bladder emptying do not restore tone.
- D. Fluids support circulating volume but do not stop the bleeding.
Which newborn finding at 18 hours of age requires immediate reporting?
Show answer and rationale
Correct answer: B. Yellow discoloration of the face and sclera
Jaundice appearing within the first 24 hours of life is pathological and usually indicates haemolysis, such as blood group incompatibility. It requires immediate evaluation and bilirubin measurement.
Why the other options are wrong
- A. Acrocyanosis is a normal finding in the first day as peripheral circulation matures.
- C. Occasional regurgitation after feeding is common in newborns.
- D. Thick dark green stool is meconium and its passage in the first 48 hours is expected and reassuring.
A client at 32 weeks of gestation calls the clinic. Which reported symptoms require the client to be seen immediately? Select all that apply.
- ASevere headache with blurred vision
- BOccasional mild heartburn after meals
- CSudden gush of clear fluid from the vagina
- DRight upper quadrant pain
- EFetal movement noticeably reduced since yesterday
Show answer and rationale
Correct answers: A. Severe headache with blurred vision; C. Sudden gush of clear fluid from the vagina; D. Right upper quadrant pain; E. Fetal movement noticeably reduced since yesterday
Severe headache with visual change and right upper quadrant pain are severe features of preeclampsia. A gush of fluid suggests rupture of membranes with a risk of preterm birth and infection. Reduced fetal movement requires prompt fetal assessment.
Why the other options are wrong
- B. Heartburn is a common discomfort of later pregnancy caused by progesterone and pressure from the growing uterus.
A 4-year-old is scheduled for a procedure. Which approach by the nurse is most developmentally appropriate?
Show answer and rationale
Correct answer: B. Use simple concrete words, allow the child to handle safe equipment, and explain shortly before the procedure
Preschoolers think concretely and have a limited sense of time, so preparation is short, simple and close to the event. Handling equipment gives a sense of control and reduces fear of bodily harm.
Why the other options are wrong
- A. A week is far too long for a preschooler and creates prolonged anxiety.
- C. Dishonesty destroys trust and makes future procedures harder.
- D. Excluding the child increases fear and does not respect their need for age-appropriate information.
A nurse runs an influenza vaccination clinic at a community centre. Which level of prevention does this represent?
Show answer and rationale
Correct answer: A. Primary prevention
Primary prevention stops disease before it occurs. Immunisation is the classic example, alongside health education, helmet use and safe food handling.
Why the other options are wrong
- B. Secondary prevention detects existing disease early, such as mammography or a screening colonoscopy.
- C. Tertiary prevention limits disability after disease is established, such as cardiac rehabilitation.
- D. This is not one of the three standard levels tested.
An 82-year-old client who has been alert and oriented becomes confused and agitated overnight. Which nursing action is most appropriate?
Show answer and rationale
Correct answer: B. Assess for infection, hypoxia, pain, dehydration and new medications
Acute confusion is delirium until proved otherwise, and delirium always has a cause. Infection, hypoxia, pain, dehydration, electrolyte disturbance and medication effects are the common culprits and are usually reversible.
Why the other options are wrong
- A. Confusion is never a normal part of aging.
- C. Sedatives commonly worsen delirium and increase fall risk.
- D. Restraints increase agitation and injury and do not treat the underlying cause.
A client at 34 weeks of gestation presents with painless bright red vaginal bleeding. Which action should the nurse avoid?
Show answer and rationale
Correct answer: B. Performing a digital vaginal examination
Painless bright red bleeding in the third trimester suggests placenta previa. A digital examination can perforate the placenta and cause catastrophic haemorrhage, so it is contraindicated until previa is excluded by ultrasound.
Why the other options are wrong
- A. External monitoring is safe and provides essential fetal information.
- C. Intravenous access is essential preparation for possible haemorrhage.
- D. Maternal vital signs are a core part of assessing blood loss.
Which client should not receive a live attenuated vaccine?
Show answer and rationale
Correct answer: B. A client receiving high-dose corticosteroid therapy
Live attenuated vaccines contain weakened organisms that can cause disease in a client whose immune system is significantly suppressed, including by high-dose corticosteroid therapy.
Why the other options are wrong
- A. A healthy infant at 12 months is the target age for several live vaccines.
- C. A minor upper respiratory illness without fever is not a contraindication.
- D. Controlled hypertension does not affect vaccine safety.
A hospitalised 9-year-old is upset about missing school and falling behind classmates. Which psychosocial stage does this reflect?
Show answer and rationale
Correct answer: C. Industry versus inferiority
School-age children develop a sense of competence through achievement and comparison with peers. Falling behind threatens that sense of industry and can produce feelings of inferiority.
Why the other options are wrong
- A. Trust versus mistrust is the infant stage.
- B. Initiative versus guilt is the preschool stage.
- D. Identity versus role confusion is the adolescent stage.
Which medication class carries the highest fall risk for an older adult and should prompt the nurse to review the necessity of the prescription?
Show answer and rationale
Correct answer: B. Benzodiazepines
Benzodiazepines cause sedation, delayed reaction time, unsteadiness and confusion, and reduced clearance in older adults prolongs these effects. They are among the highest-risk medications for falls.
Why the other options are wrong
- A. Proton pump inhibitors carry long-term fracture risk but do not directly cause unsteadiness.
- C. Statins cause myalgia in some clients but are not a leading fall risk.
- D. Inhaled corticosteroids act locally and do not cause sedation.
A nurse notes abrupt V-shaped decelerations in the fetal heart rate that are unrelated to contractions. Which action should the nurse take first?
Show answer and rationale
Correct answer: A. Reposition the client to her side
Abrupt V-shaped decelerations indicate cord compression. Maternal repositioning is the first intervention because it often shifts the fetus off the cord and resolves the pattern immediately.
Why the other options are wrong
- B. Birth is considered only if the pattern persists after intrauterine resuscitation.
- C. More contractions increase cord compression episodes.
- D. Variable decelerations are not a reassuring finding and require intervention.
A 15-year-old is admitted with a chronic illness requiring long-term treatment. Which nursing approach best supports this client’s development?
Show answer and rationale
Correct answer: B. Involve the client in decisions and arrange time with peers
Adolescents are forming identity and independence, and peer relationships are central to that. Involving them in decisions and preserving peer contact supports both developmental tasks and adherence.
Why the other options are wrong
- A. Excluding the adolescent undermines autonomy and commonly worsens adherence.
- C. Isolating an adolescent from peers is developmentally harmful.
- D. Toys are appropriate for younger children and can feel patronising to an adolescent.
A nurse observes decelerations that begin after the peak of each contraction and return to baseline after the contraction ends. Which action should the nurse take first?
Show answer and rationale
Correct answer: B. Stop the oxytocin infusion
Decelerations beginning after the peak and returning after the contraction ends are late decelerations, indicating uteroplacental insufficiency. Stopping oxytocin removes the stimulus that is reducing placental perfusion and is the first action.
Why the other options are wrong
- A. Late decelerations are never reassuring.
- C. Caesarean birth may follow if the pattern persists, but intrauterine resuscitation is attempted first.
- D. Stronger contractions further reduce placental perfusion and worsen the pattern.
After a spontaneous rupture of membranes, the nurse sees the umbilical cord protruding from the vagina. Place the nursing actions in the correct order, from first to last.
- AInsert a gloved hand and lift the presenting part off the cord
- BCall for immediate assistance
- CPosition the client in knee-chest or Trendelenburg
- DAdminister oxygen by non-rebreather mask
Show answer and rationale
Correct order: 1) A. Insert a gloved hand and lift the presenting part off the cord 2) B. Call for immediate assistance 3) C. Position the client in knee-chest or Trendelenburg 4) D. Administer oxygen by non-rebreather mask
Relieving cord compression restores fetal oxygenation immediately and is the single most important action. Help is summoned at once, positioning maintains the relief using gravity, and oxygen supports fetal reserve while the team prepares for emergency birth.
A client with severe preeclampsia is receiving magnesium sulfate. The nurse finds deep tendon reflexes absent, respirations 10 per minute, and urine output 20 millilitres in the last hour. Which action should the nurse take first?
Show answer and rationale
Correct answer: A. Stop the magnesium sulfate infusion
Absent reflexes with respiratory depression and falling urine output indicate magnesium toxicity. Stopping the infusion halts further accumulation immediately and is always the first action.
Why the other options are wrong
- B. Calcium gluconate is the antidote and is given next, but only after the source of the magnesium is stopped.
- C. Increasing fluids may support excretion but does not stop ongoing toxicity.
- D. Repositioning helps placental perfusion but does nothing about the magnesium level.
A client who gave birth three weeks ago says, "I keep thinking the baby would be better off without me." Which action should the nurse take first?
Show answer and rationale
Correct answer: B. Ask directly whether the client has thoughts of harming herself or the baby
This statement is a possible expression of suicidal thinking in the context of postpartum depression. Asking directly about intent, plan and means is the only way to assess risk, and it does not increase danger.
Why the other options are wrong
- A. Baby blues resolve within about two weeks. At three weeks with this content, the concern is depression, and reassurance minimises a serious risk.
- C. Support groups may help later, but only after safety has been established.
- D. Practical support is useful but does not assess the immediate safety risk.
What to do with your score
A single 20-item set is too short to predict a pass, so treat the number as a pointer rather than a verdict. What is worth acting on is the pattern: go back through every item you missed, and write down whether you lacked the fact, misread what the item asked for, or knew the fact and still picked second-best. Those three failures need three different fixes — more content review, slower reading, or priority-framework drilling.
Read the rationale on the items you got right too. On a well-written item you can arrive at the correct option for the wrong reason, and that will not survive a harder version of the same question.
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