NU 170 Exam 4 V1 | NU 170 Maternal-Child
Nursing | Actual Q&A with Rationale
(NU170 Exam 4) | Galen
1. A nurse is assessing a postpartum client for signs of postpartum hemorrhage (PPH). Which
of the following factors increase the client’s risk for PPH? (Select All That Apply)
A. Uterine atony
B. Placenta previa
C. Primigravida status
D. Prolonged labor
E. Magnesium sulfate infusion during labor
F. Large for gestational age (LGA) infant
Correct Answer: A, B, D, E, F
Uterine atony is the leading cause of PPH due to the failure of the uterus to contract
effectively. Factors like prolonged labor and magnesium sulfate can lead to muscle
exhaustion and relaxation, preventing contraction. Overdistention of the uterus from an
LGA infant also places the client at significant risk for hemorrhage post-delivery.
2. A nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding should the nurse prioritize as a sign of toxicity?
A. Blood pressure of 150/95 mmHg
,B. Increased urinary output
C. Absence of deep tendon reflexes
D. Respiratory rate of 16 breaths per minute
Correct Answer: C
The loss of deep tendon reflexes is an early clinical sign of magnesium sulfate toxicity. The
nurse must monitor for this frequently to prevent respiratory depression or cardiac arrest.
If reflexes are absent, the infusion must be stopped immediately and the provider notified.
3. The nurse is evaluating the Apgar score of a newborn at 1 minute. The infant has a heart
rate of 110, a slow/weak cry, some flexion of extremities, sneezes during suctioning, and a
pink body with blue extremities. What is the Apgar score?
A. 5
B. 6
C. 8
D. 7
Correct Answer: D
The score is calculated as follows: Heart rate >100 (2), slow/weak cry (1), some flexion
(1), sneeze/reflex irritability (2), and acrocyanosis (1). Adding these points results in a
total score of 7. This indicates that the newborn is in stable condition but requires
continued observation.
, 4. Which intervention is most appropriate for a nurse to implement when caring for a
newborn receiving phototherapy for hyperbilirubinemia?
A. Apply lotion to the baby’s skin to prevent drying
B. Cover the newborn’s eyes with opaque masks
C. Keep the newborn in the same position for 4 hours
D. Limit fluid intake to prevent diarrhea
Correct Answer: B
Covering the eyes is essential to protect the retina from damage caused by the high-
intensity light. The nurse should also ensure the infant is repositioned frequently to expose
all skin surfaces. Lotions should be avoided as they can cause burns under the
phototherapy lights.
5. A postpartum client who is breastfeeding complains of nipple soreness. What advice
should the nurse provide?
A. Wash nipples with soap and water after each feeding
B. Use a nipple shield for every feeding session
C. Apply a small amount of breast milk to the nipples after feeding
D. Switch to formula for 24 hours to let the nipples rest
Correct Answer: C
Nursing | Actual Q&A with Rationale
(NU170 Exam 4) | Galen
1. A nurse is assessing a postpartum client for signs of postpartum hemorrhage (PPH). Which
of the following factors increase the client’s risk for PPH? (Select All That Apply)
A. Uterine atony
B. Placenta previa
C. Primigravida status
D. Prolonged labor
E. Magnesium sulfate infusion during labor
F. Large for gestational age (LGA) infant
Correct Answer: A, B, D, E, F
Uterine atony is the leading cause of PPH due to the failure of the uterus to contract
effectively. Factors like prolonged labor and magnesium sulfate can lead to muscle
exhaustion and relaxation, preventing contraction. Overdistention of the uterus from an
LGA infant also places the client at significant risk for hemorrhage post-delivery.
2. A nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding should the nurse prioritize as a sign of toxicity?
A. Blood pressure of 150/95 mmHg
,B. Increased urinary output
C. Absence of deep tendon reflexes
D. Respiratory rate of 16 breaths per minute
Correct Answer: C
The loss of deep tendon reflexes is an early clinical sign of magnesium sulfate toxicity. The
nurse must monitor for this frequently to prevent respiratory depression or cardiac arrest.
If reflexes are absent, the infusion must be stopped immediately and the provider notified.
3. The nurse is evaluating the Apgar score of a newborn at 1 minute. The infant has a heart
rate of 110, a slow/weak cry, some flexion of extremities, sneezes during suctioning, and a
pink body with blue extremities. What is the Apgar score?
A. 5
B. 6
C. 8
D. 7
Correct Answer: D
The score is calculated as follows: Heart rate >100 (2), slow/weak cry (1), some flexion
(1), sneeze/reflex irritability (2), and acrocyanosis (1). Adding these points results in a
total score of 7. This indicates that the newborn is in stable condition but requires
continued observation.
, 4. Which intervention is most appropriate for a nurse to implement when caring for a
newborn receiving phototherapy for hyperbilirubinemia?
A. Apply lotion to the baby’s skin to prevent drying
B. Cover the newborn’s eyes with opaque masks
C. Keep the newborn in the same position for 4 hours
D. Limit fluid intake to prevent diarrhea
Correct Answer: B
Covering the eyes is essential to protect the retina from damage caused by the high-
intensity light. The nurse should also ensure the infant is repositioned frequently to expose
all skin surfaces. Lotions should be avoided as they can cause burns under the
phototherapy lights.
5. A postpartum client who is breastfeeding complains of nipple soreness. What advice
should the nurse provide?
A. Wash nipples with soap and water after each feeding
B. Use a nipple shield for every feeding session
C. Apply a small amount of breast milk to the nipples after feeding
D. Switch to formula for 24 hours to let the nipples rest
Correct Answer: C
