NU 170 Exam 3 V2 | NU 170 Maternal-Child
Nursing | Actual Q&A with Rationale
(NU170 Exam 3) | Galen
1. A nurse is reviewing the medical record of a client who is at 34 weeks of gestation and has
preeclampsia. Which of the following findings should the nurse report to the provider?
(Select all that apply)
A. Urine output of 20 mL/hr
B. Platelet count 80,000/mm3
C. Right upper quadrant pain
D. 1+ edema of the ankles
E. Blurred vision
F. Fetal heart rate 140/min
Correct Answer: A, B, C, E
Preeclampsia becomes severe when organ systems are compromised as evidenced by low
urine output, thrombocytopenia, and hepatic involvement causing RUQ pain. Blurred vision
indicates cerebral edema and potential progression to eclampsia. These findings require
immediate medical intervention to prevent maternal or fetal morbidity.
,2. A nurse is caring for a client in the first stage of labor and notes late decelerations on the
fetal heart rate monitor. Which of the following actions should the nurse take first?
A. Increase the rate of IV fluid infusion
B. Change the client’s position to lateral
C. Administer oxygen via nonrebreather mask
D. Notify the healthcare provider
Correct Answer: B
Late decelerations are caused by uteroplacental insufficiency and require immediate
intervention to improve oxygenation. Changing the client to a lateral position is the first
action to relieve pressure on the inferior vena cava and improve blood flow. After
positioning, the nurse should proceed with other resuscitation measures like fluids and
oxygen.
3. Which of the following assessments is the most critical for a nurse to perform for a client
receiving Magnesium Sulfate for preeclampsia?
A. Body temperature
B. Respiratory rate
C. Bowel sounds
D. Apical pulse
Correct Answer: B
, Magnesium sulfate is a central nervous system depressant used to prevent seizures in
preeclamptic patients. A primary sign of magnesium toxicity is respiratory depression,
characterized by a rate lower than 12 breaths per minute. Monitoring respiratory status is
vital for patient safety and to prevent respiratory arrest.
4. A newborn is 1 minute old and has a heart rate of 110, a weak cry, some flexion of
extremities, grimace when stimulated, and a pink body with blue extremities. What is the
APGAR score?
A. 5
B. 7
C. 6
D. 8
Correct Answer: C
The score is calculated as 2 for heart rate (>100), 1 for respiratory effort (weak cry), 1 for
muscle tone (some flexion), 1 for reflex irritability (grimace), and 1 for color
(acrocyanosis). This results in a total APGAR score of 6 at one minute. Scores between 4
and 6 indicate that the newborn is having some difficulty adjusting to extrauterine life.
5. A nurse is teaching the mother of a 4-year-old child about appropriate growth and
development milestones. Which of the following tasks should the child be able to perform?
A. Walks down stairs using alternating feet
B. Ties shoelaces
Nursing | Actual Q&A with Rationale
(NU170 Exam 3) | Galen
1. A nurse is reviewing the medical record of a client who is at 34 weeks of gestation and has
preeclampsia. Which of the following findings should the nurse report to the provider?
(Select all that apply)
A. Urine output of 20 mL/hr
B. Platelet count 80,000/mm3
C. Right upper quadrant pain
D. 1+ edema of the ankles
E. Blurred vision
F. Fetal heart rate 140/min
Correct Answer: A, B, C, E
Preeclampsia becomes severe when organ systems are compromised as evidenced by low
urine output, thrombocytopenia, and hepatic involvement causing RUQ pain. Blurred vision
indicates cerebral edema and potential progression to eclampsia. These findings require
immediate medical intervention to prevent maternal or fetal morbidity.
,2. A nurse is caring for a client in the first stage of labor and notes late decelerations on the
fetal heart rate monitor. Which of the following actions should the nurse take first?
A. Increase the rate of IV fluid infusion
B. Change the client’s position to lateral
C. Administer oxygen via nonrebreather mask
D. Notify the healthcare provider
Correct Answer: B
Late decelerations are caused by uteroplacental insufficiency and require immediate
intervention to improve oxygenation. Changing the client to a lateral position is the first
action to relieve pressure on the inferior vena cava and improve blood flow. After
positioning, the nurse should proceed with other resuscitation measures like fluids and
oxygen.
3. Which of the following assessments is the most critical for a nurse to perform for a client
receiving Magnesium Sulfate for preeclampsia?
A. Body temperature
B. Respiratory rate
C. Bowel sounds
D. Apical pulse
Correct Answer: B
, Magnesium sulfate is a central nervous system depressant used to prevent seizures in
preeclamptic patients. A primary sign of magnesium toxicity is respiratory depression,
characterized by a rate lower than 12 breaths per minute. Monitoring respiratory status is
vital for patient safety and to prevent respiratory arrest.
4. A newborn is 1 minute old and has a heart rate of 110, a weak cry, some flexion of
extremities, grimace when stimulated, and a pink body with blue extremities. What is the
APGAR score?
A. 5
B. 7
C. 6
D. 8
Correct Answer: C
The score is calculated as 2 for heart rate (>100), 1 for respiratory effort (weak cry), 1 for
muscle tone (some flexion), 1 for reflex irritability (grimace), and 1 for color
(acrocyanosis). This results in a total APGAR score of 6 at one minute. Scores between 4
and 6 indicate that the newborn is having some difficulty adjusting to extrauterine life.
5. A nurse is teaching the mother of a 4-year-old child about appropriate growth and
development milestones. Which of the following tasks should the child be able to perform?
A. Walks down stairs using alternating feet
B. Ties shoelaces
