NU 170 Exam 2 V3 | NU 170 Maternal-Child
Nursing | Actual Q&A with Rationale
(NU170 Exam 2) | Galen
1. A client at 34 weeks gestation presents to the triage unit with a report of sudden-onset,
severe abdominal pain and dark red vaginal bleeding. The nurse notes the abdomen is rigid
and board-like on palpation. Which condition should the nurse suspect?
A. Placenta previa
B. Uterine atony
C. Cervical insufficiency
D. Abruptio placentae
Correct Answer: D
Abruptio placentae is characterized by the premature separation of the placenta from the
uterine wall, typically presenting with painful, dark red bleeding and a rigid abdomen. This
differs from placenta previa, which is usually painless and involves bright red bleeding.
Immediate nursing priorities include monitoring maternal vital signs and fetal heart rate
patterns due to the high risk of hemorrhage and fetal distress.
,2. A nurse is monitoring a client receiving an intravenous infusion of magnesium sulfate for
the management of preeclampsia. Which assessment finding should be reported to the
provider immediately?
A. Blood pressure of 148/92 mmHg
B. Respiratory rate of 10 breaths per minute
C. Urinary output of 40 mL over the last 2 hours
D. Presence of +2 deep tendon reflexes
Correct Answer: B
A respiratory rate below 12 breaths per minute is a classic sign of magnesium sulfate
toxicity and requires immediate intervention. Other signs of toxicity include absent deep
tendon reflexes and significantly decreased urinary output. The nurse must keep calcium
gluconate at the bedside as the specific antidote for magnesium toxicity.
3. During a fetal heart rate (FHR) assessment, the nurse identifies a pattern of variable
decelerations. What is the physiological cause of this finding?
A. Umbilical cord compression
B. Uteroplacental insufficiency
C. Fetal head compression
D. Maternal hypotension
Correct Answer: A
, Variable decelerations are caused by umbilical cord compression and are often V-shaped
or U-shaped on the fetal monitor. Nursing interventions include changing the maternal
position to relieve pressure on the cord and potentially preparing for an amnioinfusion. In
contrast, early decelerations are caused by head compression and late decelerations
indicate uteroplacental insufficiency.
4. A laboring client is dilated to 6 cm and 100% effaced, with the fetus at 0 station. Which
phase of the first stage of labor is this client experiencing?
A. Latent phase
B. Transition phase
C. Active phase
D. Second stage
Correct Answer: C
The active phase of the first stage of labor is now defined as cervical dilation between 6
cm and 10 cm according to contemporary guidelines. During this phase, contractions
become more intense and frequent, typically occurring every 3 to 5 minutes. The nurse
should focus on pain management and frequent assessment of fetal well-being and labor
progress.
5. A nurse is caring for a client in the fourth stage of labor. Which of the following findings
would indicate a high risk for postpartum hemorrhage? (Select all that apply)
A. Multiparity (Grand multipara)
, B. Breech presentation
C. Prolonged labor
D. Delivery of a large-for-gestational-age (LGA) infant
E. Platelet count of 250,000/mm3
F. Retained placental fragments
Correct Answer: A,C,D,F
Risk factors for postpartum hemorrhage include anything that overstretches the uterus,
such as LGA infants or multiple gestations, and conditions that lead to uterine exhaustion
like prolonged labor. Multiparity increases the risk because the uterine muscle may have
decreased tone over time. Retained placental fragments prevent the uterus from
contracting effectively, which is essential to stop bleeding at the placental site.
6. The nurse is performing a newborn assessment 2 hours after birth. Which finding requires
further investigation?
A. Acrocyanosis
B. Heart rate of 145 beats per minute
C. Positive Moro reflex
D. Generalized petechiae
Correct Answer: D
Nursing | Actual Q&A with Rationale
(NU170 Exam 2) | Galen
1. A client at 34 weeks gestation presents to the triage unit with a report of sudden-onset,
severe abdominal pain and dark red vaginal bleeding. The nurse notes the abdomen is rigid
and board-like on palpation. Which condition should the nurse suspect?
A. Placenta previa
B. Uterine atony
C. Cervical insufficiency
D. Abruptio placentae
Correct Answer: D
Abruptio placentae is characterized by the premature separation of the placenta from the
uterine wall, typically presenting with painful, dark red bleeding and a rigid abdomen. This
differs from placenta previa, which is usually painless and involves bright red bleeding.
Immediate nursing priorities include monitoring maternal vital signs and fetal heart rate
patterns due to the high risk of hemorrhage and fetal distress.
,2. A nurse is monitoring a client receiving an intravenous infusion of magnesium sulfate for
the management of preeclampsia. Which assessment finding should be reported to the
provider immediately?
A. Blood pressure of 148/92 mmHg
B. Respiratory rate of 10 breaths per minute
C. Urinary output of 40 mL over the last 2 hours
D. Presence of +2 deep tendon reflexes
Correct Answer: B
A respiratory rate below 12 breaths per minute is a classic sign of magnesium sulfate
toxicity and requires immediate intervention. Other signs of toxicity include absent deep
tendon reflexes and significantly decreased urinary output. The nurse must keep calcium
gluconate at the bedside as the specific antidote for magnesium toxicity.
3. During a fetal heart rate (FHR) assessment, the nurse identifies a pattern of variable
decelerations. What is the physiological cause of this finding?
A. Umbilical cord compression
B. Uteroplacental insufficiency
C. Fetal head compression
D. Maternal hypotension
Correct Answer: A
, Variable decelerations are caused by umbilical cord compression and are often V-shaped
or U-shaped on the fetal monitor. Nursing interventions include changing the maternal
position to relieve pressure on the cord and potentially preparing for an amnioinfusion. In
contrast, early decelerations are caused by head compression and late decelerations
indicate uteroplacental insufficiency.
4. A laboring client is dilated to 6 cm and 100% effaced, with the fetus at 0 station. Which
phase of the first stage of labor is this client experiencing?
A. Latent phase
B. Transition phase
C. Active phase
D. Second stage
Correct Answer: C
The active phase of the first stage of labor is now defined as cervical dilation between 6
cm and 10 cm according to contemporary guidelines. During this phase, contractions
become more intense and frequent, typically occurring every 3 to 5 minutes. The nurse
should focus on pain management and frequent assessment of fetal well-being and labor
progress.
5. A nurse is caring for a client in the fourth stage of labor. Which of the following findings
would indicate a high risk for postpartum hemorrhage? (Select all that apply)
A. Multiparity (Grand multipara)
, B. Breech presentation
C. Prolonged labor
D. Delivery of a large-for-gestational-age (LGA) infant
E. Platelet count of 250,000/mm3
F. Retained placental fragments
Correct Answer: A,C,D,F
Risk factors for postpartum hemorrhage include anything that overstretches the uterus,
such as LGA infants or multiple gestations, and conditions that lead to uterine exhaustion
like prolonged labor. Multiparity increases the risk because the uterine muscle may have
decreased tone over time. Retained placental fragments prevent the uterus from
contracting effectively, which is essential to stop bleeding at the placental site.
6. The nurse is performing a newborn assessment 2 hours after birth. Which finding requires
further investigation?
A. Acrocyanosis
B. Heart rate of 145 beats per minute
C. Positive Moro reflex
D. Generalized petechiae
Correct Answer: D
