NU 170 Exam 2 V1 | NU 170 Maternal-Child
Nursing | Actual Q&A with Rationale
(NU170 Exam 2) | Galen
1. A nurse is assessing several postpartum clients for the risk of postpartum hemorrhage.
Which of the following factors should the nurse identify as increasing a client’s risk? (Select
all that apply)
A. Polyhydramnios
B. Large for gestational age (LGA) infant
C. Prolonged labor
D. Magnesium sulfate infusion
E. Multiple gestation
F. Placenta previa
Correct Answer: A, B, C, D, E, F
Uterine overdistention from polyhydramnios, multiple gestation, or an LGA infant
significantly increases the risk of uterine atony. Prolonged labor causes muscle exhaustion,
while magnesium sulfate acts as a muscle relaxant, both of which prevent effective uterine
contraction. Placenta previa increases risk because the lower uterine segment does not
contract as forcefully as the fundus.
,2. A nurse is caring for a client who is in the first stage of labor and has a fetal heart rate (FHR)
tracing showing late decelerations. Which of the following actions should the nurse take first?
A. Assist the client into a left-lateral position
B. Administer oxygen via face mask at 2 L/min
C. Increase the rate of the maintenance IV fluid
D. Perform a vaginal exam to check for cord prolapse
Correct Answer: A
Late decelerations are indicative of uteroplacental insufficiency and require immediate
intervention to improve oxygenation. Positioning the client on her left side relieves
pressure on the inferior vena cava and improves blood flow to the placenta. While oxygen
and IV fluids are appropriate interventions, repositioning is the priority action to stabilize
the fetal heart rate.
3. A nurse is providing discharge teaching to a new mother regarding newborn safety. Which
of the following instructions should the nurse include?
A. Place the infant in a prone position for sleep
B. Keep the crib near a window for natural light
C. Ensure the crib slats are no more than 2.375 inches apart
D. Use a soft mattress to prevent head flattening
Correct Answer: C
, Crib slats must be spaced closely enough to prevent the infant’s head from becoming
trapped, with the standard being no more than 2.375 inches. Infants should always be
placed in a supine position for sleep to reduce the risk of Sudden Infant Death Syndrome
(SIDS). Soft mattresses and proximity to windows with cords or drafts are safety hazards
that must be avoided.
4. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Generalized petechiae over the trunk
B. Acrocyanosis of the hands and feet
C. Respiratory rate of 50 breaths per minute
D. Milia across the bridge of the nose
Correct Answer: A
Generalized petechiae can indicate a clotting factor deficiency or infection and require
immediate medical evaluation. Acrocyanosis is a normal finding in the first 24 to 48 hours
of life due to poor peripheral circulation. A respiratory rate of 50 is within the normal
range of 30 to 60 breaths per minute for a newborn.
5. A nurse is reviewing the laboratory results of a client who is at 34 weeks of gestation and
has preeclampsia. Which of the following results should the nurse report to the provider?
A. Hemoglobin 12 g/dL
B. AST 120 units/L
, C. Platelets 160,000/mm3
D. Creatinine 0.8 mg/dL
Correct Answer: B
An elevated AST level indicates liver involvement and is a sign of HELLP syndrome, a
severe complication of preeclampsia. Normal AST levels are typically below 40 units/L, and
a value of 120 is significantly elevated. The other lab values provided fall within the
expected reference ranges for a pregnant client.
6. A nurse is caring for a client who is postpartum and receiving oxytocin for uterine atony.
Which of the following findings indicates the medication is effective?
A. The client reports increased thirst
B. Urinary output is 50 mL/hr
C. Blood pressure is 140/90 mmHg
D. The fundus is firm and at the midline
Correct Answer: D
Oxytocin is a rhythmic uterine stimulant used to promote uterine contraction and prevent
hemorrhage. A firm, midline fundus indicates that the uterus is contracting effectively and
the medication is achieving its intended therapeutic effect. Thirst and elevated blood
pressure are not indicators of oxytocin’s effectiveness in managing uterine atony.
Nursing | Actual Q&A with Rationale
(NU170 Exam 2) | Galen
1. A nurse is assessing several postpartum clients for the risk of postpartum hemorrhage.
Which of the following factors should the nurse identify as increasing a client’s risk? (Select
all that apply)
A. Polyhydramnios
B. Large for gestational age (LGA) infant
C. Prolonged labor
D. Magnesium sulfate infusion
E. Multiple gestation
F. Placenta previa
Correct Answer: A, B, C, D, E, F
Uterine overdistention from polyhydramnios, multiple gestation, or an LGA infant
significantly increases the risk of uterine atony. Prolonged labor causes muscle exhaustion,
while magnesium sulfate acts as a muscle relaxant, both of which prevent effective uterine
contraction. Placenta previa increases risk because the lower uterine segment does not
contract as forcefully as the fundus.
,2. A nurse is caring for a client who is in the first stage of labor and has a fetal heart rate (FHR)
tracing showing late decelerations. Which of the following actions should the nurse take first?
A. Assist the client into a left-lateral position
B. Administer oxygen via face mask at 2 L/min
C. Increase the rate of the maintenance IV fluid
D. Perform a vaginal exam to check for cord prolapse
Correct Answer: A
Late decelerations are indicative of uteroplacental insufficiency and require immediate
intervention to improve oxygenation. Positioning the client on her left side relieves
pressure on the inferior vena cava and improves blood flow to the placenta. While oxygen
and IV fluids are appropriate interventions, repositioning is the priority action to stabilize
the fetal heart rate.
3. A nurse is providing discharge teaching to a new mother regarding newborn safety. Which
of the following instructions should the nurse include?
A. Place the infant in a prone position for sleep
B. Keep the crib near a window for natural light
C. Ensure the crib slats are no more than 2.375 inches apart
D. Use a soft mattress to prevent head flattening
Correct Answer: C
, Crib slats must be spaced closely enough to prevent the infant’s head from becoming
trapped, with the standard being no more than 2.375 inches. Infants should always be
placed in a supine position for sleep to reduce the risk of Sudden Infant Death Syndrome
(SIDS). Soft mattresses and proximity to windows with cords or drafts are safety hazards
that must be avoided.
4. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Generalized petechiae over the trunk
B. Acrocyanosis of the hands and feet
C. Respiratory rate of 50 breaths per minute
D. Milia across the bridge of the nose
Correct Answer: A
Generalized petechiae can indicate a clotting factor deficiency or infection and require
immediate medical evaluation. Acrocyanosis is a normal finding in the first 24 to 48 hours
of life due to poor peripheral circulation. A respiratory rate of 50 is within the normal
range of 30 to 60 breaths per minute for a newborn.
5. A nurse is reviewing the laboratory results of a client who is at 34 weeks of gestation and
has preeclampsia. Which of the following results should the nurse report to the provider?
A. Hemoglobin 12 g/dL
B. AST 120 units/L
, C. Platelets 160,000/mm3
D. Creatinine 0.8 mg/dL
Correct Answer: B
An elevated AST level indicates liver involvement and is a sign of HELLP syndrome, a
severe complication of preeclampsia. Normal AST levels are typically below 40 units/L, and
a value of 120 is significantly elevated. The other lab values provided fall within the
expected reference ranges for a pregnant client.
6. A nurse is caring for a client who is postpartum and receiving oxytocin for uterine atony.
Which of the following findings indicates the medication is effective?
A. The client reports increased thirst
B. Urinary output is 50 mL/hr
C. Blood pressure is 140/90 mmHg
D. The fundus is firm and at the midline
Correct Answer: D
Oxytocin is a rhythmic uterine stimulant used to promote uterine contraction and prevent
hemorrhage. A firm, midline fundus indicates that the uterus is contracting effectively and
the medication is achieving its intended therapeutic effect. Thirst and elevated blood
pressure are not indicators of oxytocin’s effectiveness in managing uterine atony.
