NU 170 Final Exam V3 | NU 170 Maternal-
Child Nursing | Actual Q&A with Rationale
(NU170 Final Exam) | Galen
1. A nurse is assessing a client who is at 34 weeks of gestation and has a diagnosis of
preeclampsia. Which of the following findings should the nurse report to the provider as
indicative of worsening disease? (Select all that apply.)
A. 1+ pedal edema
B. Epigastric pain
C. Blurred vision or photopsia
D. Platelet count of 160,000/mm3
E. Persistent headache unresponsive to analgesics
F. Right upper quadrant pain
Correct Answer: B,C,E,F
Worsening preeclampsia, often progressing toward HELLP syndrome or eclampsia, is
characterized by signs of multi-organ involvement. Epigastric or right upper quadrant pain
typically indicates liver swelling or subcapsular hematoma. Neurological symptoms like
blurred vision and persistent headaches are significant warning signs of increased central
nervous system irritability and potential seizures.
,2. A nurse is caring for a client in the first stage of labor who is experiencing late
decelerations on the fetal heart rate monitor. Which of the following actions should the nurse
take first?
A. Administer oxygen via a non-rebreather mask
B. Perform a vaginal examination to check for cord prolapse
C. Increase the rate of the intravenous infusion
D. Turn the client to a side-lying position
Correct Answer: D
Late decelerations indicate uteroplacental insufficiency and require immediate
intervention to improve oxygenation to the fetus. Maternal positioning is the first action to
relieve pressure on the vena cava and improve blood flow to the placenta. While oxygen
and IV fluids are appropriate subsequent steps, repositioning is the most rapid way to
improve perfusion.
3. A nurse is teaching a parent of a 4-year-old child about age-appropriate activities. Which of
the following activities should the nurse recommend?
A. Building a 200-piece puzzle
B. Playing with a large ball in a group
C. Solitary play with blocks
D. Putting together a large-piece puzzle or coloring
,Correct Answer: D
Preschool-age children, such as 4-year-olds, are developing fine motor skills and enjoy
activities like coloring and simple puzzles. They engage in associative play rather than the
cooperative play required for complex sports or games. At this age, they are mastering the
use of scissors and drawing recognizable shapes, making creative play highly appropriate.
4. A nurse is evaluating a client who is 12 hours postpartum. The nurse notes the fundus is
firm, two fingerbreadths above the umbilicus, and deviated to the right. Which of the
following actions should the nurse take?
A. Assist the client to the bathroom to void
B. Administer oxytocin per standing orders
C. Massage the fundus vigorously
D. Notify the provider of potential hemorrhage
Correct Answer: A
A fundus that is displaced upward and to the right usually indicates a distended bladder. A
full bladder prevents the uterus from contracting efficiently, which increases the risk of
postpartum hemorrhage. Assisting the client to empty their bladder will allow the uterus to
return to the midline and its proper position.
5. A nurse is providing discharge teaching to the parents of a newborn regarding car seat
safety. Which of the following instructions should the nurse include?
A. The car seat should be front-facing once the child reaches 15 pounds
, B. The car seat should be placed at a 45-degree angle
C. Use a heavy blanket between the baby and the harness during winter
D. Place the car seat in the front passenger seat if there is an airbag
Correct Answer: B
Newborns should be placed in a rear-facing car seat at a 45-degree angle to prevent
airway obstruction from the head slumping forward. It is essential that the harness is snug
and that no bulky clothing or blankets are placed between the baby and the straps. Rear-
facing positioning is recommended until at least 2 years of age or until the child reaches the
maximum height or weight for the seat.
6. A nurse is caring for a child with suspected epiglottitis. Which of the following actions is the
nurse’s priority?
A. Obtain a throat culture to identify the pathogen
B. Apply a warm humidified mist tent
C. Ensure emergency intubation equipment is at the bedside
D. Visualize the airway using a tongue blade
Correct Answer: C
Epiglotittis is a medical emergency that can lead to rapid and total airway obstruction. The
nurse must never attempt to visualize the throat with a tongue blade as this can trigger a
Child Nursing | Actual Q&A with Rationale
(NU170 Final Exam) | Galen
1. A nurse is assessing a client who is at 34 weeks of gestation and has a diagnosis of
preeclampsia. Which of the following findings should the nurse report to the provider as
indicative of worsening disease? (Select all that apply.)
A. 1+ pedal edema
B. Epigastric pain
C. Blurred vision or photopsia
D. Platelet count of 160,000/mm3
E. Persistent headache unresponsive to analgesics
F. Right upper quadrant pain
Correct Answer: B,C,E,F
Worsening preeclampsia, often progressing toward HELLP syndrome or eclampsia, is
characterized by signs of multi-organ involvement. Epigastric or right upper quadrant pain
typically indicates liver swelling or subcapsular hematoma. Neurological symptoms like
blurred vision and persistent headaches are significant warning signs of increased central
nervous system irritability and potential seizures.
,2. A nurse is caring for a client in the first stage of labor who is experiencing late
decelerations on the fetal heart rate monitor. Which of the following actions should the nurse
take first?
A. Administer oxygen via a non-rebreather mask
B. Perform a vaginal examination to check for cord prolapse
C. Increase the rate of the intravenous infusion
D. Turn the client to a side-lying position
Correct Answer: D
Late decelerations indicate uteroplacental insufficiency and require immediate
intervention to improve oxygenation to the fetus. Maternal positioning is the first action to
relieve pressure on the vena cava and improve blood flow to the placenta. While oxygen
and IV fluids are appropriate subsequent steps, repositioning is the most rapid way to
improve perfusion.
3. A nurse is teaching a parent of a 4-year-old child about age-appropriate activities. Which of
the following activities should the nurse recommend?
A. Building a 200-piece puzzle
B. Playing with a large ball in a group
C. Solitary play with blocks
D. Putting together a large-piece puzzle or coloring
,Correct Answer: D
Preschool-age children, such as 4-year-olds, are developing fine motor skills and enjoy
activities like coloring and simple puzzles. They engage in associative play rather than the
cooperative play required for complex sports or games. At this age, they are mastering the
use of scissors and drawing recognizable shapes, making creative play highly appropriate.
4. A nurse is evaluating a client who is 12 hours postpartum. The nurse notes the fundus is
firm, two fingerbreadths above the umbilicus, and deviated to the right. Which of the
following actions should the nurse take?
A. Assist the client to the bathroom to void
B. Administer oxytocin per standing orders
C. Massage the fundus vigorously
D. Notify the provider of potential hemorrhage
Correct Answer: A
A fundus that is displaced upward and to the right usually indicates a distended bladder. A
full bladder prevents the uterus from contracting efficiently, which increases the risk of
postpartum hemorrhage. Assisting the client to empty their bladder will allow the uterus to
return to the midline and its proper position.
5. A nurse is providing discharge teaching to the parents of a newborn regarding car seat
safety. Which of the following instructions should the nurse include?
A. The car seat should be front-facing once the child reaches 15 pounds
, B. The car seat should be placed at a 45-degree angle
C. Use a heavy blanket between the baby and the harness during winter
D. Place the car seat in the front passenger seat if there is an airbag
Correct Answer: B
Newborns should be placed in a rear-facing car seat at a 45-degree angle to prevent
airway obstruction from the head slumping forward. It is essential that the harness is snug
and that no bulky clothing or blankets are placed between the baby and the straps. Rear-
facing positioning is recommended until at least 2 years of age or until the child reaches the
maximum height or weight for the seat.
6. A nurse is caring for a child with suspected epiglottitis. Which of the following actions is the
nurse’s priority?
A. Obtain a throat culture to identify the pathogen
B. Apply a warm humidified mist tent
C. Ensure emergency intubation equipment is at the bedside
D. Visualize the airway using a tongue blade
Correct Answer: C
Epiglotittis is a medical emergency that can lead to rapid and total airway obstruction. The
nurse must never attempt to visualize the throat with a tongue blade as this can trigger a
