NU 170 Final Exam V2 | NU 170 Maternal-
Child Nursing | Actual Q&A with Rationale
(NU170 Final Exam) | Galen
1. A nurse is assessing a client at 34 weeks gestation diagnosed with severe preeclampsia.
Which of the following findings should the nurse expect? (Select all that apply)
A. Proteinuria of 3+ or greater
B. Epigastric or right upper quadrant pain
C. Hypotension
D. Visual disturbances such as blurred vision or spots
E. Hyperreflexia and presence of clonus
F. Persistent, severe headache
Correct Answer: A, B, D, E, F
Severe preeclampsia is characterized by multisystem organ involvement beyond just
elevated blood pressure. Symptoms like epigastric pain and visual disturbances indicate
hepatic and central nervous system involvement, respectively. The nurse must prioritize
monitoring for these signs to prevent progression to eclampsia and potential seizures.
2. A nurse is caring for a client in the active phase of labor. The nurse notes the fetal heart
rate (FHR) shows late decelerations. Which of the following is the priority action?
A. Increase the rate of the oxytocin infusion
,B. Perform a vaginal examination to check for cord prolapse
C. Position the client in a lateral or side-lying position
D. Prepare the client for an immediate vacuum-assisted delivery
Correct Answer: C
Late decelerations are indicative of uteroplacental insufficiency, which reduces oxygen
delivery to the fetus. Repositioning the client to a side-lying position improves uterine
blood flow and placental perfusion by relieving pressure on the vena cava. This is the
priority intervention followed by oxygen administration and discontinuing oxytocin if
applicable.
3. A nurse is calculating an Apgar score for a newborn at 1 min of age. The infant has a heart
rate of 110/min, a slow/weak cry, some flexion of extremities, grimace when stimulated, and
a pink body with blue extremities. What is the Apgar score?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
The infant receives 2 points for heart rate (>100), 1 point for respiratory effort
(slow/weak), 1 point for muscle tone (some flexion), 1 point for reflex irritability
,(grimace), and 1 point for color (acrocyanosis). Totaling these points results in a score of 6.
This score indicates that the newborn may require some resuscitation efforts or close
monitoring.
4. A nurse is providing discharge teaching to a client who is 2 days postpartum and is
breastfeeding. Which of the following statements by the client indicates an understanding of
the teaching?
A. ‘I will use soap to clean my nipples during my shower.’
B. ‘I should feed my baby on a strict schedule every 4 hours.’
C. ‘I should supplement with water if the baby seems thirsty between feedings.’
D. ‘I will apply a few drops of breast milk to my nipples after each feeding.’
Correct Answer: D
Applying breast milk to the nipples helps prevent soreness and provides natural anti-
infective properties. Using soap can be drying and lead to cracked nipples, which increases
the risk of mastitis. Breastfeeding should be done on demand rather than a strict schedule
to ensure adequate milk supply and infant growth.
5. A nurse is assessing a client who is 2 hours postpartum. Which of the following findings is
the priority to report to the provider?
A. Urine output of 100 mL over 2 hours
B. Lochia rubra with small clots
C. Fundus at the level of the umbilicus and firm
, D. Saturation of a perineal pad in 15 minutes
Correct Answer: D
Saturating a perineal pad in 15 minutes or less is a sign of excessive bleeding and potential
postpartum hemorrhage. This requires immediate nursing intervention, such as fundal
massage and notification of the provider. While lochia rubra and a firm fundus are normal
findings, rapid saturation of a pad indicates a critical change in status.
6. A nurse is caring for a client who is in the third trimester of pregnancy and has a
prescription for a nonstress test (NST). Which of the following instructions should the nurse
provide?
A. ‘You will press a button whenever you feel the baby move.’
B. ‘You will be asked to drink a glucose solution prior to the procedure.’
C. ‘You will need to remain NPO for 4 hours before the test.’
D. ‘This test will determine if you are in early labor.’
Correct Answer: A
The NST evaluates fetal well-being by monitoring the fetal heart rate response to fetal
movement. A reactive test, which is a positive sign, shows at least two accelerations of 15
beats/min lasting 15 seconds over a 20-minute period. The client presses a marker button
to record movements so the nurse can correlate them with the FHR strip.
Child Nursing | Actual Q&A with Rationale
(NU170 Final Exam) | Galen
1. A nurse is assessing a client at 34 weeks gestation diagnosed with severe preeclampsia.
Which of the following findings should the nurse expect? (Select all that apply)
A. Proteinuria of 3+ or greater
B. Epigastric or right upper quadrant pain
C. Hypotension
D. Visual disturbances such as blurred vision or spots
E. Hyperreflexia and presence of clonus
F. Persistent, severe headache
Correct Answer: A, B, D, E, F
Severe preeclampsia is characterized by multisystem organ involvement beyond just
elevated blood pressure. Symptoms like epigastric pain and visual disturbances indicate
hepatic and central nervous system involvement, respectively. The nurse must prioritize
monitoring for these signs to prevent progression to eclampsia and potential seizures.
2. A nurse is caring for a client in the active phase of labor. The nurse notes the fetal heart
rate (FHR) shows late decelerations. Which of the following is the priority action?
A. Increase the rate of the oxytocin infusion
,B. Perform a vaginal examination to check for cord prolapse
C. Position the client in a lateral or side-lying position
D. Prepare the client for an immediate vacuum-assisted delivery
Correct Answer: C
Late decelerations are indicative of uteroplacental insufficiency, which reduces oxygen
delivery to the fetus. Repositioning the client to a side-lying position improves uterine
blood flow and placental perfusion by relieving pressure on the vena cava. This is the
priority intervention followed by oxygen administration and discontinuing oxytocin if
applicable.
3. A nurse is calculating an Apgar score for a newborn at 1 min of age. The infant has a heart
rate of 110/min, a slow/weak cry, some flexion of extremities, grimace when stimulated, and
a pink body with blue extremities. What is the Apgar score?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
The infant receives 2 points for heart rate (>100), 1 point for respiratory effort
(slow/weak), 1 point for muscle tone (some flexion), 1 point for reflex irritability
,(grimace), and 1 point for color (acrocyanosis). Totaling these points results in a score of 6.
This score indicates that the newborn may require some resuscitation efforts or close
monitoring.
4. A nurse is providing discharge teaching to a client who is 2 days postpartum and is
breastfeeding. Which of the following statements by the client indicates an understanding of
the teaching?
A. ‘I will use soap to clean my nipples during my shower.’
B. ‘I should feed my baby on a strict schedule every 4 hours.’
C. ‘I should supplement with water if the baby seems thirsty between feedings.’
D. ‘I will apply a few drops of breast milk to my nipples after each feeding.’
Correct Answer: D
Applying breast milk to the nipples helps prevent soreness and provides natural anti-
infective properties. Using soap can be drying and lead to cracked nipples, which increases
the risk of mastitis. Breastfeeding should be done on demand rather than a strict schedule
to ensure adequate milk supply and infant growth.
5. A nurse is assessing a client who is 2 hours postpartum. Which of the following findings is
the priority to report to the provider?
A. Urine output of 100 mL over 2 hours
B. Lochia rubra with small clots
C. Fundus at the level of the umbilicus and firm
, D. Saturation of a perineal pad in 15 minutes
Correct Answer: D
Saturating a perineal pad in 15 minutes or less is a sign of excessive bleeding and potential
postpartum hemorrhage. This requires immediate nursing intervention, such as fundal
massage and notification of the provider. While lochia rubra and a firm fundus are normal
findings, rapid saturation of a pad indicates a critical change in status.
6. A nurse is caring for a client who is in the third trimester of pregnancy and has a
prescription for a nonstress test (NST). Which of the following instructions should the nurse
provide?
A. ‘You will press a button whenever you feel the baby move.’
B. ‘You will be asked to drink a glucose solution prior to the procedure.’
C. ‘You will need to remain NPO for 4 hours before the test.’
D. ‘This test will determine if you are in early labor.’
Correct Answer: A
The NST evaluates fetal well-being by monitoring the fetal heart rate response to fetal
movement. A reactive test, which is a positive sign, shows at least two accelerations of 15
beats/min lasting 15 seconds over a 20-minute period. The client presses a marker button
to record movements so the nurse can correlate them with the FHR strip.
