NU 170 Exam 2 V2 | NU 170 Maternal-Child
Nursing | Actual Q&A with Rationale
(NU170 Exam 2) | Galen
1. A nurse is assessing a client who is 12 hours postpartum. The nurse notes that the uterine
fundus is boggy and displaced to the right. Which of the following actions should the nurse
take first?
A. Assist the client to the bathroom to void
B. Massage the fundus until firm
C. Administer oxytocin 10 units IM
D. Notify the provider immediately
Correct Answer: A
A displaced fundus to the right or left usually indicates a full bladder, which prevents the
uterus from contracting effectively. Assisting the client to void allows the uterus to return
to the midline and contract to prevent hemorrhage. This is the priority intervention before
considering pharmacological or invasive measures.
2. A nurse is evaluating the fetal heart rate (FHR) monitor strip of a client in active labor. The
nurse notes several late decelerations. Which of the following interventions are appropriate
for this client? (Select All That Apply)
A. Increase the rate of maintenance IV fluids
,B. Reposition the client to a side-lying position
C. Place the client in a high-Fowler’s position
D. Administer oxygen at 8 to 10 L/min via nonrebreather mask
E. Discontinue the oxytocin infusion if running
F. Perform a vaginal exam to check for cord prolapse
Correct Answer: A, B, D, E
Late decelerations are caused by uteroplacental insufficiency and require immediate
intrauterine resuscitation. Nursing actions include turning the client to their side to
improve blood flow, increasing IV fluids to expand volume, and providing oxygen to
maximize fetal oxygenation. Discontinuing oxytocin is critical to reduce uterine activity and
stress on the fetus.
3. A nurse is providing discharge teaching to a new mother regarding newborn safety and
SIDS prevention. Which instruction should the nurse include?
A. Place the infant in a supine position on a firm mattress for all sleep
B. Place the infant on their side to sleep to prevent aspiration
C. Use a soft mattress to provide comfort for the infant
D. Keep stuffed animals and extra blankets in the crib for warmth
Correct Answer: A
, Safe sleep practices mandate that infants be placed on their backs (supine) for every sleep
period to reduce the risk of SIDS. The mattress should be firm, and the crib should be free
of loose bedding, pillows, or toys. These evidence-based guidelines have significantly
decreased infant mortality rates related to sleep accidents.
4. A nurse is caring for a client who is in labor and receiving magnesium sulfate for
preeclampsia. Which of the following findings should the nurse report to the provider as a
sign of magnesium toxicity?
A. Deep tendon reflexes of 2+
B. Respiratory rate of 10 breaths per minute
C. Urine output of 40 mL/hr
D. Blood pressure of 150/95 mmHg
Correct Answer: B
Magnesium sulfate toxicity is a life-threatening complication that manifests as central
nervous system depression. Signs include a respiratory rate less than 12, loss of deep
tendon reflexes, and decreased urinary output. The nurse must monitor these parameters
hourly and have calcium gluconate available as an antidote.
5. A nurse is caring for a neonate born at 39 weeks gestation. Which of the following
assessment findings is considered normal for a 24-hour-old newborn?
A. Jaundice appearing on the face and chest
B. The presence of vernix caseosa in skin folds
, C. A heart rate of 100 beats per minute while crying
D. Nasal flaring and intercostal retractions
Correct Answer: B
Vernix caseosa is a cheese-like substance that protects the skin in utero and is common in
full-term infants. Jaundice within the first 24 hours is considered pathological and requires
further investigation. Normal newborn heart rates should be higher (110-160) and
respiratory distress signs like flaring are never normal.
6. A client at 28 weeks gestation has a negative Rubella titer. Which of the following is the
correct nursing action?
A. Administer the MMR vaccine immediately to prevent infection
B. Advise the client to avoid all children until delivery
C. Inform the client that she will receive the vaccine after delivery
D. Administer Rho(D) immune globulin to protect the fetus
Correct Answer: C
The MMR vaccine contains a live virus and is contraindicated during pregnancy due to the
risk of teratogenic effects on the fetus. A client who is non-immune should be educated to
avoid exposure to rubella during pregnancy. The vaccine is administered in the immediate
postpartum period, and the client should be advised to avoid pregnancy for at least one
month following the shot.
Nursing | Actual Q&A with Rationale
(NU170 Exam 2) | Galen
1. A nurse is assessing a client who is 12 hours postpartum. The nurse notes that the uterine
fundus is boggy and displaced to the right. Which of the following actions should the nurse
take first?
A. Assist the client to the bathroom to void
B. Massage the fundus until firm
C. Administer oxytocin 10 units IM
D. Notify the provider immediately
Correct Answer: A
A displaced fundus to the right or left usually indicates a full bladder, which prevents the
uterus from contracting effectively. Assisting the client to void allows the uterus to return
to the midline and contract to prevent hemorrhage. This is the priority intervention before
considering pharmacological or invasive measures.
2. A nurse is evaluating the fetal heart rate (FHR) monitor strip of a client in active labor. The
nurse notes several late decelerations. Which of the following interventions are appropriate
for this client? (Select All That Apply)
A. Increase the rate of maintenance IV fluids
,B. Reposition the client to a side-lying position
C. Place the client in a high-Fowler’s position
D. Administer oxygen at 8 to 10 L/min via nonrebreather mask
E. Discontinue the oxytocin infusion if running
F. Perform a vaginal exam to check for cord prolapse
Correct Answer: A, B, D, E
Late decelerations are caused by uteroplacental insufficiency and require immediate
intrauterine resuscitation. Nursing actions include turning the client to their side to
improve blood flow, increasing IV fluids to expand volume, and providing oxygen to
maximize fetal oxygenation. Discontinuing oxytocin is critical to reduce uterine activity and
stress on the fetus.
3. A nurse is providing discharge teaching to a new mother regarding newborn safety and
SIDS prevention. Which instruction should the nurse include?
A. Place the infant in a supine position on a firm mattress for all sleep
B. Place the infant on their side to sleep to prevent aspiration
C. Use a soft mattress to provide comfort for the infant
D. Keep stuffed animals and extra blankets in the crib for warmth
Correct Answer: A
, Safe sleep practices mandate that infants be placed on their backs (supine) for every sleep
period to reduce the risk of SIDS. The mattress should be firm, and the crib should be free
of loose bedding, pillows, or toys. These evidence-based guidelines have significantly
decreased infant mortality rates related to sleep accidents.
4. A nurse is caring for a client who is in labor and receiving magnesium sulfate for
preeclampsia. Which of the following findings should the nurse report to the provider as a
sign of magnesium toxicity?
A. Deep tendon reflexes of 2+
B. Respiratory rate of 10 breaths per minute
C. Urine output of 40 mL/hr
D. Blood pressure of 150/95 mmHg
Correct Answer: B
Magnesium sulfate toxicity is a life-threatening complication that manifests as central
nervous system depression. Signs include a respiratory rate less than 12, loss of deep
tendon reflexes, and decreased urinary output. The nurse must monitor these parameters
hourly and have calcium gluconate available as an antidote.
5. A nurse is caring for a neonate born at 39 weeks gestation. Which of the following
assessment findings is considered normal for a 24-hour-old newborn?
A. Jaundice appearing on the face and chest
B. The presence of vernix caseosa in skin folds
, C. A heart rate of 100 beats per minute while crying
D. Nasal flaring and intercostal retractions
Correct Answer: B
Vernix caseosa is a cheese-like substance that protects the skin in utero and is common in
full-term infants. Jaundice within the first 24 hours is considered pathological and requires
further investigation. Normal newborn heart rates should be higher (110-160) and
respiratory distress signs like flaring are never normal.
6. A client at 28 weeks gestation has a negative Rubella titer. Which of the following is the
correct nursing action?
A. Administer the MMR vaccine immediately to prevent infection
B. Advise the client to avoid all children until delivery
C. Inform the client that she will receive the vaccine after delivery
D. Administer Rho(D) immune globulin to protect the fetus
Correct Answer: C
The MMR vaccine contains a live virus and is contraindicated during pregnancy due to the
risk of teratogenic effects on the fetus. A client who is non-immune should be educated to
avoid exposure to rubella during pregnancy. The vaccine is administered in the immediate
postpartum period, and the client should be advised to avoid pregnancy for at least one
month following the shot.
