NU 170 Exam 3 | Maternal-Child Nursing Study Guide 2026 Galen
College
1. A nurse is monitoring a fetal heart rate (FHR) tracing and notes late
decelerations. Which of the following is the priority nursing action?
A. Position the client on her left side
B. Increase the rate of the oxytocin infusion
C. Perform a vaginal examination
D. Administer oxygen at 2 L/min via nasal cannula
Answer: A
Rationale: Late decelerations are indicative of uteroplacental insufficiency. The first action
should be to improve placental perfusion by positioning the mother on her side. Oxygen
should be given via non-rebreather mask at 8-10L, and oxytocin should be stopped, not
increased.
2. A postpartum patient is experiencing a heavy vaginal bleed and the fundus is
found to be soft and boggy, displaced to the right. What is the first action the
nurse should take?
A. Perform fundal massage
B. Assist the patient to the bathroom to void
C. Notify the provider immediately
D. Administer oxytocin IV
Answer: B
Rationale: A boggy uterus displaced to the right usually indicates a full bladder, which
prevents the uterus from contracting. Emptying the bladder is the priority to allow the
fundus to return to midline and contract.
,3. Which of the following findings is a classic sign of placenta previa?
A. Painful, rigid abdomen
B. Dark red vaginal bleeding with severe pain
C. Painless, bright red vaginal bleeding
D. Persistent low back pain and uterine tenderness
Answer: C
Rationale: Placenta previa is characterized by painless, bright red bleeding in the third
trimester as the cervix begins to dilate. Painful, dark bleeding is associated with abruptio
placentae.
4. A newborn has an APGAR score of 9 at 1 minute. The nurse notes the baby
has a heart rate of 110, a strong cry, some flexion of extremities, sneezing when
stimulated, and a pink body with blue hands and feet. Which point was
deducted?
A. Respiratory effort
B. Muscle tone
C. Reflex irritability
D. Skin color (Appearance)
Answer: D
Rationale: A pink body with blue extremities (acrocyanosis) earns 1 point for appearance.
A score of 2 requires the whole body to be pink. All other categories described earned the
full 2 points.
, 5. According to Erikson, which developmental task is primary for a toddler (1-3
years old)?
A. Autonomy vs. Shame and Doubt
B. Trust vs. Mistrust
C. Initiative vs. Guilt
D. Industry vs. Inferiority
Answer: A
Rationale: Toddlers are in the stage of Autonomy vs. Shame and Doubt, where they seek to
gain control over bodily functions and environment (the ‘no’ stage).
6. A nurse is caring for a client receiving Magnesium Sulfate for preeclampsia.
Which finding would indicate magnesium toxicity?
A. Blood pressure of 150/95
B. Presence of 2+ patellar reflexes
C. Urinary output of 40 mL/hr
D. Respiratory rate of 10 breaths/min
Answer: D
Rationale: Signs of Magnesium toxicity include respiratory depression (RR <12), loss of
deep tendon reflexes, and decreased urinary output (<30mL/hr).
7. A child with Tetralogy of Fallot becomes cyanotic and dyspneic during a crying
spell. In which position should the nurse place the child?
A. Knee-chest
B. High-Fowler’s
C. Trendelenburg
D. Supine with legs elevated
Answer: A
Rationale: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt in the heart and improves oxygenation during a ‘Tet spell.’
College
1. A nurse is monitoring a fetal heart rate (FHR) tracing and notes late
decelerations. Which of the following is the priority nursing action?
A. Position the client on her left side
B. Increase the rate of the oxytocin infusion
C. Perform a vaginal examination
D. Administer oxygen at 2 L/min via nasal cannula
Answer: A
Rationale: Late decelerations are indicative of uteroplacental insufficiency. The first action
should be to improve placental perfusion by positioning the mother on her side. Oxygen
should be given via non-rebreather mask at 8-10L, and oxytocin should be stopped, not
increased.
2. A postpartum patient is experiencing a heavy vaginal bleed and the fundus is
found to be soft and boggy, displaced to the right. What is the first action the
nurse should take?
A. Perform fundal massage
B. Assist the patient to the bathroom to void
C. Notify the provider immediately
D. Administer oxytocin IV
Answer: B
Rationale: A boggy uterus displaced to the right usually indicates a full bladder, which
prevents the uterus from contracting. Emptying the bladder is the priority to allow the
fundus to return to midline and contract.
,3. Which of the following findings is a classic sign of placenta previa?
A. Painful, rigid abdomen
B. Dark red vaginal bleeding with severe pain
C. Painless, bright red vaginal bleeding
D. Persistent low back pain and uterine tenderness
Answer: C
Rationale: Placenta previa is characterized by painless, bright red bleeding in the third
trimester as the cervix begins to dilate. Painful, dark bleeding is associated with abruptio
placentae.
4. A newborn has an APGAR score of 9 at 1 minute. The nurse notes the baby
has a heart rate of 110, a strong cry, some flexion of extremities, sneezing when
stimulated, and a pink body with blue hands and feet. Which point was
deducted?
A. Respiratory effort
B. Muscle tone
C. Reflex irritability
D. Skin color (Appearance)
Answer: D
Rationale: A pink body with blue extremities (acrocyanosis) earns 1 point for appearance.
A score of 2 requires the whole body to be pink. All other categories described earned the
full 2 points.
, 5. According to Erikson, which developmental task is primary for a toddler (1-3
years old)?
A. Autonomy vs. Shame and Doubt
B. Trust vs. Mistrust
C. Initiative vs. Guilt
D. Industry vs. Inferiority
Answer: A
Rationale: Toddlers are in the stage of Autonomy vs. Shame and Doubt, where they seek to
gain control over bodily functions and environment (the ‘no’ stage).
6. A nurse is caring for a client receiving Magnesium Sulfate for preeclampsia.
Which finding would indicate magnesium toxicity?
A. Blood pressure of 150/95
B. Presence of 2+ patellar reflexes
C. Urinary output of 40 mL/hr
D. Respiratory rate of 10 breaths/min
Answer: D
Rationale: Signs of Magnesium toxicity include respiratory depression (RR <12), loss of
deep tendon reflexes, and decreased urinary output (<30mL/hr).
7. A child with Tetralogy of Fallot becomes cyanotic and dyspneic during a crying
spell. In which position should the nurse place the child?
A. Knee-chest
B. High-Fowler’s
C. Trendelenburg
D. Supine with legs elevated
Answer: A
Rationale: The knee-chest position increases systemic vascular resistance, which helps
reduce the right-to-left shunt in the heart and improves oxygenation during a ‘Tet spell.’
