NU 170 Exam 4 V2 | NU 170 Maternal-Child
Nursing | Actual Q&A with Rationale
(NU170 Exam 4) | Galen
1. A nurse is assessing a client who is 2 hours postpartum and observes that the fundus is
boggy and displaced to the right of the midline. What is the priority nursing action?
A. Administer oxytocin via intravenous infusion.
B. Perform vigorous fundal massage.
C. Notify the provider of potential hemorrhage.
D. Assist the client to the bathroom to void.
Correct Answer: D
A displaced fundus to the right is a classic sign of bladder distention, which prevents the
uterus from contracting effectively. The nurse should first assist the client to empty their
bladder to allow the uterus to return to the midline and firm up. If the fundus remains
boggy after voiding, then massage and pharmacological interventions would be
appropriate.
2. A nurse is caring for a newborn immediately following birth. Which of the following actions
should the nurse take first?
A. Administer vitamin K intramuscularly.
B. Apply erythromycin ophthalmic ointment.
,C. Dry the newborn and provide a warm environment.
D. Obtain the newborn’s weight and length.
Correct Answer: C
Thermoregulation is a priority for the newborn to prevent cold stress, which can lead to
metabolic acidosis and respiratory distress. Drying the infant immediately removes
moisture that causes heat loss through evaporation. Other routine cares like medications
and measurements can be delayed until the infant is stabilized and dry.
3. A nurse is providing discharge teaching to the parents of a newborn regarding safe sleep
practices. Which of the following instructions should the nurse include? (Select All That
Apply)
A. Place the newborn on their back to sleep.
B. Keep the crib free of blankets, pillows, and stuffed animals.
C. Allow the newborn to sleep in a car seat if they are comfortable.
D. Use a firm sleep surface covered by a fitted sheet.
E. Dress the newborn in multiple layers to prevent shivering.
F. Avoid sharing a bed with the newborn during sleep.
Correct Answer: A, B, D, F
Safe sleep guidelines involve placing the infant in a supine position on a firm mattress
without any loose bedding or soft objects to reduce the risk of Sudden Infant Death
, Syndrome (SIDS). Bed-sharing is discouraged due to the risk of accidental suffocation or
overlay. Overheating should be avoided, so multiple heavy layers are not recommended.
4. A client at 34 weeks of gestation is 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. Urine output of 40 mL per hour.
C. Respiratory rate of 10 breaths per minute.
D. Client report of feeling warm and flushed.
Correct Answer: C
Magnesium sulfate is a central nervous system depressant; toxicity is characterized by
respiratory depression, loss of deep tendon reflexes, and decreased urinary output. A
respiratory rate below 12 breaths per minute is a critical indicator that the magnesium
infusion should be stopped and the provider notified. Feeling warm or flushed is a common
side effect of the medication but not a sign of toxicity.
5. A nurse is assessing a newborn 1 minute after birth and finds: heart rate 110/min,
slow/irregular respirations, some flexion of extremities, grimace when suctioned, and body
pink with blue extremities. What is the Apgar score?
A. 6
B. 5
Nursing | Actual Q&A with Rationale
(NU170 Exam 4) | Galen
1. A nurse is assessing a client who is 2 hours postpartum and observes that the fundus is
boggy and displaced to the right of the midline. What is the priority nursing action?
A. Administer oxytocin via intravenous infusion.
B. Perform vigorous fundal massage.
C. Notify the provider of potential hemorrhage.
D. Assist the client to the bathroom to void.
Correct Answer: D
A displaced fundus to the right is a classic sign of bladder distention, which prevents the
uterus from contracting effectively. The nurse should first assist the client to empty their
bladder to allow the uterus to return to the midline and firm up. If the fundus remains
boggy after voiding, then massage and pharmacological interventions would be
appropriate.
2. A nurse is caring for a newborn immediately following birth. Which of the following actions
should the nurse take first?
A. Administer vitamin K intramuscularly.
B. Apply erythromycin ophthalmic ointment.
,C. Dry the newborn and provide a warm environment.
D. Obtain the newborn’s weight and length.
Correct Answer: C
Thermoregulation is a priority for the newborn to prevent cold stress, which can lead to
metabolic acidosis and respiratory distress. Drying the infant immediately removes
moisture that causes heat loss through evaporation. Other routine cares like medications
and measurements can be delayed until the infant is stabilized and dry.
3. A nurse is providing discharge teaching to the parents of a newborn regarding safe sleep
practices. Which of the following instructions should the nurse include? (Select All That
Apply)
A. Place the newborn on their back to sleep.
B. Keep the crib free of blankets, pillows, and stuffed animals.
C. Allow the newborn to sleep in a car seat if they are comfortable.
D. Use a firm sleep surface covered by a fitted sheet.
E. Dress the newborn in multiple layers to prevent shivering.
F. Avoid sharing a bed with the newborn during sleep.
Correct Answer: A, B, D, F
Safe sleep guidelines involve placing the infant in a supine position on a firm mattress
without any loose bedding or soft objects to reduce the risk of Sudden Infant Death
, Syndrome (SIDS). Bed-sharing is discouraged due to the risk of accidental suffocation or
overlay. Overheating should be avoided, so multiple heavy layers are not recommended.
4. A client at 34 weeks of gestation is 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. Urine output of 40 mL per hour.
C. Respiratory rate of 10 breaths per minute.
D. Client report of feeling warm and flushed.
Correct Answer: C
Magnesium sulfate is a central nervous system depressant; toxicity is characterized by
respiratory depression, loss of deep tendon reflexes, and decreased urinary output. A
respiratory rate below 12 breaths per minute is a critical indicator that the magnesium
infusion should be stopped and the provider notified. Feeling warm or flushed is a common
side effect of the medication but not a sign of toxicity.
5. A nurse is assessing a newborn 1 minute after birth and finds: heart rate 110/min,
slow/irregular respirations, some flexion of extremities, grimace when suctioned, and body
pink with blue extremities. What is the Apgar score?
A. 6
B. 5
