NU 170 Final Exam V1 | NU 170 Maternal-
Child Nursing | Actual Q&A with Rationale
(NU170 Final Exam) | Galen
1. A nurse is assessing a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate. Which of the following findings should the nurse identify as signs of
magnesium toxicity? (Select all that apply.)
A. Respiratory rate less than 12/min
B. Absence of deep tendon reflexes
C. Urine output less than 30 mL/hr
D. Decreased level of consciousness
E. Increased blood pressure
F. Tachycardia
Correct Answer: A, B, C, D
Magnesium toxicity is a critical emergency that results in central nervous system and
respiratory depression. The nurse must monitor for decreased respiratory effort, the loss
of patellar reflexes, and oliguria which indicates the kidneys are not excreting the
magnesium. Immediate intervention with calcium gluconate is required if these symptoms
are observed to prevent cardiac arrest.
,2. A nurse is caring for a client in the first stage of labor and observes early decelerations on
the fetal heart rate monitor. Which of the following actions should the nurse take?
A. Increase the rate of the IV fluid infusion
B. Continue to monitor the client
C. Administer oxygen via non-rebreather mask
D. Notify the provider of fetal distress
Correct Answer: B
Early decelerations are typically caused by fetal head compression during contractions
and are considered a benign finding. They usually mirror the contraction and do not
require specific medical intervention or intrauterine resuscitation. The nurse should
simply continue documentation and routine observation of the labor progress.
3. A nurse is teaching a parent of a toddler about safety and injury prevention. Which of the
following instructions should the nurse include?
A. Turn pot handles toward the back of the stove
B. Place a small pillow in the toddler’s crib for comfort
C. Set the water heater temperature to 130 degrees Fahrenheit
D. Store cleaning supplies in a low, unlocked cabinet
Correct Answer: A
, Toddlers are naturally curious and often reach for objects above their eye level, making
burns from stove pots a significant risk. Turning handles inward prevents the child from
grabbing them and pulling hot contents down. Safety teaching must also include lowering
water heater temperatures to 120 degrees and locking all chemical storage areas.
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
B. Acrocyanosis of the hands and feet
C. Heart rate of 140/min
D. Milia on the nose
Correct Answer: A
Generalized petechiae in a newborn can indicate a serious underlying clotting disorder or
infection and must be evaluated immediately. While acrocyanosis is a normal finding due to
peripheral circulation immaturity, petechiae over the whole body are not. Milia and a heart
rate of 140 are expected and healthy findings in the early neonatal period.
5. A nurse is caring for a client who is 2 hours postpartum and has a boggy uterus with heavy
lochia rubra. Which of the following medications should the nurse expect to administer?
A. Magnesium sulfate
B. Terbutaline
C. Oxytocin
, D. Betamethasone
Correct Answer: C
Oxytocin is the first-line medication used to stimulate uterine contractions and manage
postpartum hemorrhage. A boggy uterus indicates uterine atony, which prevents the
compression of blood vessels at the placental site. By inducing firm contractions, oxytocin
helps reduce bleeding and stabilizes the client’s hemodynamic status.
6. A nurse is assessing a child with pyloric stenosis. Which of the following clinical
manifestations should the nurse expect?
A. Currant jelly stools
B. Projectile vomiting
C. Steatorrhea
D. Bile-stained vomitus
Correct Answer: B
Hypertrophic pyloric stenosis causes a physical obstruction at the outlet of the stomach,
leading to forceful, non-bile stained projectile vomiting. This condition typically presents in
infants between 3 to 6 weeks of age and often includes an olive-shaped mass in the
epigastrium. Currant jelly stools are more characteristic of intussusception rather than
pyloric stenosis.
Child Nursing | Actual Q&A with Rationale
(NU170 Final Exam) | Galen
1. A nurse is assessing a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate. Which of the following findings should the nurse identify as signs of
magnesium toxicity? (Select all that apply.)
A. Respiratory rate less than 12/min
B. Absence of deep tendon reflexes
C. Urine output less than 30 mL/hr
D. Decreased level of consciousness
E. Increased blood pressure
F. Tachycardia
Correct Answer: A, B, C, D
Magnesium toxicity is a critical emergency that results in central nervous system and
respiratory depression. The nurse must monitor for decreased respiratory effort, the loss
of patellar reflexes, and oliguria which indicates the kidneys are not excreting the
magnesium. Immediate intervention with calcium gluconate is required if these symptoms
are observed to prevent cardiac arrest.
,2. A nurse is caring for a client in the first stage of labor and observes early decelerations on
the fetal heart rate monitor. Which of the following actions should the nurse take?
A. Increase the rate of the IV fluid infusion
B. Continue to monitor the client
C. Administer oxygen via non-rebreather mask
D. Notify the provider of fetal distress
Correct Answer: B
Early decelerations are typically caused by fetal head compression during contractions
and are considered a benign finding. They usually mirror the contraction and do not
require specific medical intervention or intrauterine resuscitation. The nurse should
simply continue documentation and routine observation of the labor progress.
3. A nurse is teaching a parent of a toddler about safety and injury prevention. Which of the
following instructions should the nurse include?
A. Turn pot handles toward the back of the stove
B. Place a small pillow in the toddler’s crib for comfort
C. Set the water heater temperature to 130 degrees Fahrenheit
D. Store cleaning supplies in a low, unlocked cabinet
Correct Answer: A
, Toddlers are naturally curious and often reach for objects above their eye level, making
burns from stove pots a significant risk. Turning handles inward prevents the child from
grabbing them and pulling hot contents down. Safety teaching must also include lowering
water heater temperatures to 120 degrees and locking all chemical storage areas.
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
B. Acrocyanosis of the hands and feet
C. Heart rate of 140/min
D. Milia on the nose
Correct Answer: A
Generalized petechiae in a newborn can indicate a serious underlying clotting disorder or
infection and must be evaluated immediately. While acrocyanosis is a normal finding due to
peripheral circulation immaturity, petechiae over the whole body are not. Milia and a heart
rate of 140 are expected and healthy findings in the early neonatal period.
5. A nurse is caring for a client who is 2 hours postpartum and has a boggy uterus with heavy
lochia rubra. Which of the following medications should the nurse expect to administer?
A. Magnesium sulfate
B. Terbutaline
C. Oxytocin
, D. Betamethasone
Correct Answer: C
Oxytocin is the first-line medication used to stimulate uterine contractions and manage
postpartum hemorrhage. A boggy uterus indicates uterine atony, which prevents the
compression of blood vessels at the placental site. By inducing firm contractions, oxytocin
helps reduce bleeding and stabilizes the client’s hemodynamic status.
6. A nurse is assessing a child with pyloric stenosis. Which of the following clinical
manifestations should the nurse expect?
A. Currant jelly stools
B. Projectile vomiting
C. Steatorrhea
D. Bile-stained vomitus
Correct Answer: B
Hypertrophic pyloric stenosis causes a physical obstruction at the outlet of the stomach,
leading to forceful, non-bile stained projectile vomiting. This condition typically presents in
infants between 3 to 6 weeks of age and often includes an olive-shaped mass in the
epigastrium. Currant jelly stools are more characteristic of intussusception rather than
pyloric stenosis.
