NU 170 Exam 3 V3 | NU 170 Maternal-Child
Nursing | Actual Q&A with Rationale
(NU170 Exam 3) | Galen
1. A nurse is assessing a client 2 hours postpartum. Which findings should the nurse identify
as risk factors for postpartum hemorrhage (Select All That Apply)?
A. History of a large-for-gestational-age infant
B. First-time mother (Primipara)
C. Prolonged labor exceeding 24 hours
D. Magnesium sulfate infusion during labor
E. Chorioamnionitis during the intrapartum period
F. Breastfeeding within the first hour
Correct Answer: A, C, D, E
Uterine overdistension from a large infant and muscle exhaustion from prolonged labor
significantly increase the risk of uterine atony. Magnesium sulfate is a muscle relaxant that
can inhibit uterine contractions postpartum, further predisposing the client to bleeding.
Infection such as chorioamnionitis impairs the ability of the uterine muscle to contract
effectively after delivery.
,2. A nurse is evaluating a newborn’s APGAR score at 1 minute. The infant has a heart rate of
110/min, a slow/irregular respiratory effort, some flexion of extremities, a grimace in
response to a catheter in the nostril, and a pink body with blue extremities. What is the
assigned score?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
The infant receives 2 points for heart rate over 100, 1 point for respiratory effort, 1 point
for muscle tone, 1 point for reflex irritability, and 1 point for color. Adding these values
(2+1+1+1+1) results in a total score of 6. This indicates the newborn is having some
difficulty transitioning and requires close observation or intervention.
3. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which
assessment finding should the nurse prioritize and report to the provider?
A. Blood pressure of 150/95 mmHg
B. Respirations of 10 breaths per minute
C. 2+ deep tendon reflexes
D. Urinary output of 40 mL/hr
,Correct Answer: B
Respiratory depression is a critical sign of magnesium sulfate toxicity and must be
addressed immediately to prevent respiratory arrest. The nurse should also monitor for
absent deep tendon reflexes and a significant drop in urinary output. If toxicity is
suspected, the infusion must be stopped and calcium gluconate should be readily available
as the antidote.
4. A nurse is preparing to administer Vitamin K (phytonadione) to a newborn. What is the
primary rationale for this medication?
A. To prevent ophthalmia neonatorum from birth canal bacteria
B. To stimulate the production of red blood cells
C. To prevent vitamin K deficiency bleeding due to lack of intestinal flora
D. To provide immediate passive immunity against viral infections
Correct Answer: C
Newborns are born with a sterile gut and lack the bacteria necessary to synthesize
Vitamin K, which is essential for the production of clotting factors. Administering an
intramuscular injection of Vitamin K shortly after birth prevents potentially life-
threatening hemorrhagic disease. This is a standard prophylactic treatment for all neonates
regardless of the delivery method.
, 5. A nurse is educating a postpartum client about breastfeeding. Which statements by the
client indicate a correct understanding of the teaching (Select All That Apply)?
A. ‘I should expect my baby to nurse about 8 to 12 times in a 24-hour period.’
B. ‘I will supplement with formula if my baby seems hungry after nursing.’
C. ‘I can tell my baby is getting enough milk if there are 6 to 8 wet diapers a day.’
D. ‘I should use a timer and nurse for exactly 10 minutes on each side.’
E. ‘My baby’s stools will eventually become yellow and seedy.’
Correct Answer: A, C, E
Frequent nursing is necessary to establish milk supply and meet the nutritional needs of
the newborn during the early postpartum period. Adequate hydration and intake are
evidenced by the number of wet diapers and the transition of meconium to yellow, seedy
stools. Supplements and strict timing are discouraged as they can interfere with the supply-
and-demand nature of breastfeeding.
6. A nurse is assessing a newborn 12 hours after birth. Which finding requires immediate
intervention?
A. Acrocyanosis of the hands and feet
B. Small white spots on the bridge of the nose (milia)
C. Passage of a dark green, sticky stool
D. Substernal retractions and grunting
Nursing | Actual Q&A with Rationale
(NU170 Exam 3) | Galen
1. A nurse is assessing a client 2 hours postpartum. Which findings should the nurse identify
as risk factors for postpartum hemorrhage (Select All That Apply)?
A. History of a large-for-gestational-age infant
B. First-time mother (Primipara)
C. Prolonged labor exceeding 24 hours
D. Magnesium sulfate infusion during labor
E. Chorioamnionitis during the intrapartum period
F. Breastfeeding within the first hour
Correct Answer: A, C, D, E
Uterine overdistension from a large infant and muscle exhaustion from prolonged labor
significantly increase the risk of uterine atony. Magnesium sulfate is a muscle relaxant that
can inhibit uterine contractions postpartum, further predisposing the client to bleeding.
Infection such as chorioamnionitis impairs the ability of the uterine muscle to contract
effectively after delivery.
,2. A nurse is evaluating a newborn’s APGAR score at 1 minute. The infant has a heart rate of
110/min, a slow/irregular respiratory effort, some flexion of extremities, a grimace in
response to a catheter in the nostril, and a pink body with blue extremities. What is the
assigned score?
A. 5
B. 8
C. 7
D. 6
Correct Answer: D
The infant receives 2 points for heart rate over 100, 1 point for respiratory effort, 1 point
for muscle tone, 1 point for reflex irritability, and 1 point for color. Adding these values
(2+1+1+1+1) results in a total score of 6. This indicates the newborn is having some
difficulty transitioning and requires close observation or intervention.
3. A nurse is caring for a client receiving magnesium sulfate for preeclampsia. Which
assessment finding should the nurse prioritize and report to the provider?
A. Blood pressure of 150/95 mmHg
B. Respirations of 10 breaths per minute
C. 2+ deep tendon reflexes
D. Urinary output of 40 mL/hr
,Correct Answer: B
Respiratory depression is a critical sign of magnesium sulfate toxicity and must be
addressed immediately to prevent respiratory arrest. The nurse should also monitor for
absent deep tendon reflexes and a significant drop in urinary output. If toxicity is
suspected, the infusion must be stopped and calcium gluconate should be readily available
as the antidote.
4. A nurse is preparing to administer Vitamin K (phytonadione) to a newborn. What is the
primary rationale for this medication?
A. To prevent ophthalmia neonatorum from birth canal bacteria
B. To stimulate the production of red blood cells
C. To prevent vitamin K deficiency bleeding due to lack of intestinal flora
D. To provide immediate passive immunity against viral infections
Correct Answer: C
Newborns are born with a sterile gut and lack the bacteria necessary to synthesize
Vitamin K, which is essential for the production of clotting factors. Administering an
intramuscular injection of Vitamin K shortly after birth prevents potentially life-
threatening hemorrhagic disease. This is a standard prophylactic treatment for all neonates
regardless of the delivery method.
, 5. A nurse is educating a postpartum client about breastfeeding. Which statements by the
client indicate a correct understanding of the teaching (Select All That Apply)?
A. ‘I should expect my baby to nurse about 8 to 12 times in a 24-hour period.’
B. ‘I will supplement with formula if my baby seems hungry after nursing.’
C. ‘I can tell my baby is getting enough milk if there are 6 to 8 wet diapers a day.’
D. ‘I should use a timer and nurse for exactly 10 minutes on each side.’
E. ‘My baby’s stools will eventually become yellow and seedy.’
Correct Answer: A, C, E
Frequent nursing is necessary to establish milk supply and meet the nutritional needs of
the newborn during the early postpartum period. Adequate hydration and intake are
evidenced by the number of wet diapers and the transition of meconium to yellow, seedy
stools. Supplements and strict timing are discouraged as they can interfere with the supply-
and-demand nature of breastfeeding.
6. A nurse is assessing a newborn 12 hours after birth. Which finding requires immediate
intervention?
A. Acrocyanosis of the hands and feet
B. Small white spots on the bridge of the nose (milia)
C. Passage of a dark green, sticky stool
D. Substernal retractions and grunting
