NU 170 Exam 4 V3 | NU 170 Maternal-Child
Nursing | Actual Q&A with Rationale
(NU170 Exam 4) | Galen
1. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse identify as manifestations of respiratory distress? (Select all that apply.)
A. Nasal flaring
B. Intercostal retractions
C. Expiratory grunting
D. Tachypnea greater than 60/min
E. Seesaw breathing
F. Acrocyanosis
Correct Answer: A, B, C, D, E
Respiratory distress in a newborn is characterized by the use of accessory muscles and
compensatory mechanisms to improve oxygenation. Acrocyanosis is a normal finding in the
first 24 to 48 hours of life and does not indicate respiratory distress. The nurse must
monitor for these signs closely to prevent respiratory failure.
2. A nurse is performing a fundal assessment on a client who is 12 hours postpartum. Where
should the nurse expect to find the fundus?
A. 2 cm above the umbilicus
,B. 4 cm below the umbilicus
C. At the level of the symphysis pubis
D. 1 cm above the umbilicus
Correct Answer: D
At approximately 12 hours postpartum, the fundus is typically located 1 cm above the
umbilicus. After this point, the fundus should descend about 1 to 2 cm every 24 hours. A
fundus that is higher than expected or deviated to the right may indicate a full bladder.
3. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings should the nurse report to the provider as a sign of magnesium
toxicity?
A. Increased urine output
B. Blood pressure 150/96 mmHg
C. Absence of deep tendon reflexes
D. Respiratory rate of 16/min
Correct Answer: C
Magnesium toxicity suppresses the central nervous system, leading to the loss of deep
tendon reflexes. Other signs include respiratory depression, decreased urinary output, and
cardiac arrest. The nurse should have calcium gluconate available as the antidote.
, 4. A nurse is assessing a newborn at 1 minute and 5 minutes after birth. At 1 minute, the
newborn has a heart rate of 110/min, a slow/weak cry, some flexion of the extremities,
grimace when stimulated, and a pink body with blue extremities. What is the 1-minute
APGAR score?
A. 6
B. 5
C. 7
D. 8
Correct Answer: A
The APGAR score is calculated by giving 2 points for heart rate >100, 1 point for slow cry,
1 point for some flexion, 1 point for grimace, and 1 point for acrocyanosis. This results in a
total score of 6. Scores below 7 at 5 minutes require further intervention or repeated
assessment.
5. A nurse is teaching the parents of a newborn about phototherapy for neonatal jaundice.
Which of the following instructions should the nurse include?
A. Apply lotion to the newborn’s skin before treatment.
B. Offer the newborn plain water between feedings.
C. Keep the newborn dressed in a diaper and a shirt.
D. Keep the newborn’s eyes covered with a mask during treatment.
Nursing | Actual Q&A with Rationale
(NU170 Exam 4) | Galen
1. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse identify as manifestations of respiratory distress? (Select all that apply.)
A. Nasal flaring
B. Intercostal retractions
C. Expiratory grunting
D. Tachypnea greater than 60/min
E. Seesaw breathing
F. Acrocyanosis
Correct Answer: A, B, C, D, E
Respiratory distress in a newborn is characterized by the use of accessory muscles and
compensatory mechanisms to improve oxygenation. Acrocyanosis is a normal finding in the
first 24 to 48 hours of life and does not indicate respiratory distress. The nurse must
monitor for these signs closely to prevent respiratory failure.
2. A nurse is performing a fundal assessment on a client who is 12 hours postpartum. Where
should the nurse expect to find the fundus?
A. 2 cm above the umbilicus
,B. 4 cm below the umbilicus
C. At the level of the symphysis pubis
D. 1 cm above the umbilicus
Correct Answer: D
At approximately 12 hours postpartum, the fundus is typically located 1 cm above the
umbilicus. After this point, the fundus should descend about 1 to 2 cm every 24 hours. A
fundus that is higher than expected or deviated to the right may indicate a full bladder.
3. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings should the nurse report to the provider as a sign of magnesium
toxicity?
A. Increased urine output
B. Blood pressure 150/96 mmHg
C. Absence of deep tendon reflexes
D. Respiratory rate of 16/min
Correct Answer: C
Magnesium toxicity suppresses the central nervous system, leading to the loss of deep
tendon reflexes. Other signs include respiratory depression, decreased urinary output, and
cardiac arrest. The nurse should have calcium gluconate available as the antidote.
, 4. A nurse is assessing a newborn at 1 minute and 5 minutes after birth. At 1 minute, the
newborn has a heart rate of 110/min, a slow/weak cry, some flexion of the extremities,
grimace when stimulated, and a pink body with blue extremities. What is the 1-minute
APGAR score?
A. 6
B. 5
C. 7
D. 8
Correct Answer: A
The APGAR score is calculated by giving 2 points for heart rate >100, 1 point for slow cry,
1 point for some flexion, 1 point for grimace, and 1 point for acrocyanosis. This results in a
total score of 6. Scores below 7 at 5 minutes require further intervention or repeated
assessment.
5. A nurse is teaching the parents of a newborn about phototherapy for neonatal jaundice.
Which of the following instructions should the nurse include?
A. Apply lotion to the newborn’s skin before treatment.
B. Offer the newborn plain water between feedings.
C. Keep the newborn dressed in a diaper and a shirt.
D. Keep the newborn’s eyes covered with a mask during treatment.
