NU 170 Exam 3 V1 | NU 170 Maternal-Child
Nursing | Actual Q&A with Rationale
(NU170 Exam 3) | Galen
1. A nurse is monitoring a client who is at 37 weeks of gestation and has severe preeclampsia.
Which of the following findings should the nurse report to the provider immediately?
A. Blood pressure of 150/95 mmHg
B. 1+ pitting edema in lower extremities
C. Urine output of 40 mL/hr
D. Epigastric pain
Correct Answer: D
Epigastric pain is a clinical manifestation of severe preeclampsia and may indicate hepatic
involvement or impending seizure (eclampsia). The nurse must prioritize this finding as it
suggests a worsening of the disease process. Immediate notification of the provider is
necessary to prevent further complications such as HELLP syndrome.
2. A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory rates
is within the expected reference range?
A. 20 breaths/min
B. 100 breaths/min
C. 72 breaths/min
,D. 48 breaths/min
Correct Answer: D
The normal respiratory rate for a newborn ranges from 30 to 60 breaths per minute.
Rates below 30 or above 60 may indicate respiratory distress or other underlying issues. It
is important for the nurse to assess the rate when the infant is at rest for the most accurate
measurement.
3. A client in the active phase of labor receives an epidural block. Which of the following is
the priority nursing action?
A. Assess the client’s bladder for distention
B. Monitor the fetal heart rate
C. Position the client on her side
D. Monitor maternal blood pressure
Correct Answer: D
Maternal hypotension is a common side effect of epidural anesthesia due to vasodilation.
The nurse must prioritize monitoring the blood pressure to ensure adequate placental
perfusion. If hypotension occurs, nursing interventions such as IV fluid boluses and lateral
positioning are implemented.
4. A nurse is caring for a 4-year-old child following a tonsillectomy. Which of the following is a
sign of postoperative hemorrhage?
A. Refusal to drink citrus juices
, B. Frequent swallowing
C. Nasal congestion
D. Halitosis
Correct Answer: B
Frequent swallowing in a post-tonsillectomy patient is often a subtle sign of bleeding from
the surgical site. The child may be swallowing blood that is trickling down the back of the
throat. The nurse should inspect the throat with a flashlight to confirm the presence of
active bleeding.
5. A nurse is assessing a client for suspected placental abruption. Which clinical
manifestations should the nurse expect? (Select All That Apply)
A. Sudden onset of dark red vaginal bleeding
B. Rigid, board-like abdomen
C. Severe uterine tenderness
D. Painless, bright red vaginal bleeding
E. Abnormal fetal heart rate patterns
F. Soft, relaxed uterus
Correct Answer: A,B,C,E
Placental abruption is characterized by the premature separation of the placenta from the
uterine wall, leading to painful bleeding and uterine rigidity. Unlike placenta previa, which
Nursing | Actual Q&A with Rationale
(NU170 Exam 3) | Galen
1. A nurse is monitoring a client who is at 37 weeks of gestation and has severe preeclampsia.
Which of the following findings should the nurse report to the provider immediately?
A. Blood pressure of 150/95 mmHg
B. 1+ pitting edema in lower extremities
C. Urine output of 40 mL/hr
D. Epigastric pain
Correct Answer: D
Epigastric pain is a clinical manifestation of severe preeclampsia and may indicate hepatic
involvement or impending seizure (eclampsia). The nurse must prioritize this finding as it
suggests a worsening of the disease process. Immediate notification of the provider is
necessary to prevent further complications such as HELLP syndrome.
2. A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory rates
is within the expected reference range?
A. 20 breaths/min
B. 100 breaths/min
C. 72 breaths/min
,D. 48 breaths/min
Correct Answer: D
The normal respiratory rate for a newborn ranges from 30 to 60 breaths per minute.
Rates below 30 or above 60 may indicate respiratory distress or other underlying issues. It
is important for the nurse to assess the rate when the infant is at rest for the most accurate
measurement.
3. A client in the active phase of labor receives an epidural block. Which of the following is
the priority nursing action?
A. Assess the client’s bladder for distention
B. Monitor the fetal heart rate
C. Position the client on her side
D. Monitor maternal blood pressure
Correct Answer: D
Maternal hypotension is a common side effect of epidural anesthesia due to vasodilation.
The nurse must prioritize monitoring the blood pressure to ensure adequate placental
perfusion. If hypotension occurs, nursing interventions such as IV fluid boluses and lateral
positioning are implemented.
4. A nurse is caring for a 4-year-old child following a tonsillectomy. Which of the following is a
sign of postoperative hemorrhage?
A. Refusal to drink citrus juices
, B. Frequent swallowing
C. Nasal congestion
D. Halitosis
Correct Answer: B
Frequent swallowing in a post-tonsillectomy patient is often a subtle sign of bleeding from
the surgical site. The child may be swallowing blood that is trickling down the back of the
throat. The nurse should inspect the throat with a flashlight to confirm the presence of
active bleeding.
5. A nurse is assessing a client for suspected placental abruption. Which clinical
manifestations should the nurse expect? (Select All That Apply)
A. Sudden onset of dark red vaginal bleeding
B. Rigid, board-like abdomen
C. Severe uterine tenderness
D. Painless, bright red vaginal bleeding
E. Abnormal fetal heart rate patterns
F. Soft, relaxed uterus
Correct Answer: A,B,C,E
Placental abruption is characterized by the premature separation of the placenta from the
uterine wall, leading to painful bleeding and uterine rigidity. Unlike placenta previa, which
