NU 171 Exam 4 | Maternal Child Nursing
Nursing Practice Exam (2026/2027) - Galen College
(1) A nurse is caring for a client in labor who is receiving an oxytocin infusion. The nurse notes
contractions occur every 90 seconds and last 100 seconds. What is the priority nursing action?
A. Increase the oxytocin rate.
B. Stop the oxytocin infusion.
C. Administer an analgesic.
D. Reposition the client to the right side.
CORRECT ANSWER: B
Clinical Rationale: This indicates uterine tachysystole (hyperstimulation), which can lead to fetal
distress. The priority is to stop the oxytocin to allow the uterus to rest and improve fetal oxygenation.
(2) A client at 38 weeks gestation presents with sudden, painless, bright red vaginal bleeding.
Which condition should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Uterine rupture
D. Preterm labor
CORRECT ANSWER: B
Clinical Rationale: Painless, bright red bleeding is the classic sign of placenta previa. Abruptio
placentae usually involves painful, dark red bleeding with uterine rigidity.
(3) A postpartum nurse is assessing a client 2 hours after delivery. The fundus is boggy and
displaced to the right. What is the first action the nurse should take?
A. Massage the fundus.
B. Notify the provider.
C. Assist the client to the bathroom to void.
D. Administer methylergonovine.
CORRECT ANSWER: C
Clinical Rationale: A displaced fundus is typically caused by a full bladder. Once the bladder is
emptied, the fundus usually returns to the midline and becomes firm. If it remains boggy after voiding,
massage is then the next step.
,(4) Which assessment finding in a 2-hour-old neonate requires immediate intervention by the
nurse?
A. Acrocyanosis
B. Nasal flaring and grunting
C. A heart rate of 140 bpm
D. Blood glucose of 50 mg/dL
CORRECT ANSWER: B
Clinical Rationale: Nasal flaring, grunting, and intercostal retractions are signs of respiratory distress
syndrome in the newborn and require immediate attention. Acrocyanosis is normal in the first 24
hours.
(5) A nurse is preparing to administer Vitamin K to a newborn. What is the rationale for this
medication?
A. To prevent infection.
B. To promote lung maturity.
C. To prevent hemorrhagic disease of the newborn.
D. To stimulate the first bowel movement.
CORRECT ANSWER: C
Clinical Rationale: Newborns are born with low levels of Vitamin K because it does not cross the
placenta easily and the sterile gut hasn't started producing it. Vitamin K is essential for clotting factor
synthesis.
(6) A toddler is brought to the ER with a 'barking' cough and inspiratory stridor. Which
condition is most likely?
A. Asthma
B. Bronchiolitis
C. Croup (Laryngotracheobronchitis)
D. Cystic Fibrosis
CORRECT ANSWER: C
Clinical Rationale: Croup is characterized by edema of the larynx and trachea, resulting in a distinct
barking cough and inspiratory stridor.
,(7) An infant is admitted with suspected pyloric stenosis. Which finding is the nurse most likely
to observe?
A. Currant jelly stools
B. Projectile vomiting after feedings
C. Steatorrhea
D. Lower abdominal pain
CORRECT ANSWER: B
Clinical Rationale: Projectile, non-bilious vomiting after feeding and an olive-shaped mass in the
epigastrium are hallmark signs of hypertrophic pyloric stenosis.
(8) A nurse is teaching parents about Hirschsprung's disease. How should the nurse describe
this condition?
A. An absence of ganglion cells in the colon.
B. A telescoping of one part of the bowel into another.
C. A protrusion of the bowel through the umbilical ring.
D. A malformation of the anorectal opening.
CORRECT ANSWER: A
Clinical Rationale: Hirschsprung's disease is a mechanical obstruction caused by inadequate motility
in a segment of the colon due to missing nerve cells (ganglion cells).
(9) A child with Tetralogy of Fallot is having a 'tet spell.' Which position should the nurse place
the child in?
A. Prone
B. High-Fowler's
C. Knee-chest position
D. Supine with legs extended
CORRECT ANSWER: C
Clinical Rationale: The knee-chest position increases systemic vascular resistance, which helps reduce
the right-to-left shunt and improves pulmonary blood flow during a cyanotic spell.
, (10) Which medication is the antidote for Magnesium Sulfate toxicity in a client with
preeclampsia?
A. Naloxone
B. Protamine sulfate
C. Calcium gluconate
D. Vitamin K
CORRECT ANSWER: C
Clinical Rationale: Calcium gluconate is the specific antagonist for magnesium and should be kept at
the bedside whenever a magnesium infusion is running.
(11) A nurse is caring for a client in labor who is receiving an oxytocin infusion. The nurse notes
contractions occur every 90 seconds and last 100 seconds. What is the priority nursing action?
A. Increase the oxytocin rate.
B. Stop the oxytocin infusion.
C. Administer an analgesic.
D. Reposition the client to the right side.
CORRECT ANSWER: B
Clinical Rationale: This indicates uterine tachysystole (hyperstimulation), which can lead to fetal
distress. The priority is to stop the oxytocin to allow the uterus to rest and improve fetal oxygenation.
(12) A client at 38 weeks gestation presents with sudden, painless, bright red vaginal bleeding.
Which condition should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Uterine rupture
D. Preterm labor
CORRECT ANSWER: B
Clinical Rationale: Painless, bright red bleeding is the classic sign of placenta previa. Abruptio
placentae usually involves painful, dark red bleeding with uterine rigidity.
Nursing Practice Exam (2026/2027) - Galen College
(1) A nurse is caring for a client in labor who is receiving an oxytocin infusion. The nurse notes
contractions occur every 90 seconds and last 100 seconds. What is the priority nursing action?
A. Increase the oxytocin rate.
B. Stop the oxytocin infusion.
C. Administer an analgesic.
D. Reposition the client to the right side.
CORRECT ANSWER: B
Clinical Rationale: This indicates uterine tachysystole (hyperstimulation), which can lead to fetal
distress. The priority is to stop the oxytocin to allow the uterus to rest and improve fetal oxygenation.
(2) A client at 38 weeks gestation presents with sudden, painless, bright red vaginal bleeding.
Which condition should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Uterine rupture
D. Preterm labor
CORRECT ANSWER: B
Clinical Rationale: Painless, bright red bleeding is the classic sign of placenta previa. Abruptio
placentae usually involves painful, dark red bleeding with uterine rigidity.
(3) A postpartum nurse is assessing a client 2 hours after delivery. The fundus is boggy and
displaced to the right. What is the first action the nurse should take?
A. Massage the fundus.
B. Notify the provider.
C. Assist the client to the bathroom to void.
D. Administer methylergonovine.
CORRECT ANSWER: C
Clinical Rationale: A displaced fundus is typically caused by a full bladder. Once the bladder is
emptied, the fundus usually returns to the midline and becomes firm. If it remains boggy after voiding,
massage is then the next step.
,(4) Which assessment finding in a 2-hour-old neonate requires immediate intervention by the
nurse?
A. Acrocyanosis
B. Nasal flaring and grunting
C. A heart rate of 140 bpm
D. Blood glucose of 50 mg/dL
CORRECT ANSWER: B
Clinical Rationale: Nasal flaring, grunting, and intercostal retractions are signs of respiratory distress
syndrome in the newborn and require immediate attention. Acrocyanosis is normal in the first 24
hours.
(5) A nurse is preparing to administer Vitamin K to a newborn. What is the rationale for this
medication?
A. To prevent infection.
B. To promote lung maturity.
C. To prevent hemorrhagic disease of the newborn.
D. To stimulate the first bowel movement.
CORRECT ANSWER: C
Clinical Rationale: Newborns are born with low levels of Vitamin K because it does not cross the
placenta easily and the sterile gut hasn't started producing it. Vitamin K is essential for clotting factor
synthesis.
(6) A toddler is brought to the ER with a 'barking' cough and inspiratory stridor. Which
condition is most likely?
A. Asthma
B. Bronchiolitis
C. Croup (Laryngotracheobronchitis)
D. Cystic Fibrosis
CORRECT ANSWER: C
Clinical Rationale: Croup is characterized by edema of the larynx and trachea, resulting in a distinct
barking cough and inspiratory stridor.
,(7) An infant is admitted with suspected pyloric stenosis. Which finding is the nurse most likely
to observe?
A. Currant jelly stools
B. Projectile vomiting after feedings
C. Steatorrhea
D. Lower abdominal pain
CORRECT ANSWER: B
Clinical Rationale: Projectile, non-bilious vomiting after feeding and an olive-shaped mass in the
epigastrium are hallmark signs of hypertrophic pyloric stenosis.
(8) A nurse is teaching parents about Hirschsprung's disease. How should the nurse describe
this condition?
A. An absence of ganglion cells in the colon.
B. A telescoping of one part of the bowel into another.
C. A protrusion of the bowel through the umbilical ring.
D. A malformation of the anorectal opening.
CORRECT ANSWER: A
Clinical Rationale: Hirschsprung's disease is a mechanical obstruction caused by inadequate motility
in a segment of the colon due to missing nerve cells (ganglion cells).
(9) A child with Tetralogy of Fallot is having a 'tet spell.' Which position should the nurse place
the child in?
A. Prone
B. High-Fowler's
C. Knee-chest position
D. Supine with legs extended
CORRECT ANSWER: C
Clinical Rationale: The knee-chest position increases systemic vascular resistance, which helps reduce
the right-to-left shunt and improves pulmonary blood flow during a cyanotic spell.
, (10) Which medication is the antidote for Magnesium Sulfate toxicity in a client with
preeclampsia?
A. Naloxone
B. Protamine sulfate
C. Calcium gluconate
D. Vitamin K
CORRECT ANSWER: C
Clinical Rationale: Calcium gluconate is the specific antagonist for magnesium and should be kept at
the bedside whenever a magnesium infusion is running.
(11) A nurse is caring for a client in labor who is receiving an oxytocin infusion. The nurse notes
contractions occur every 90 seconds and last 100 seconds. What is the priority nursing action?
A. Increase the oxytocin rate.
B. Stop the oxytocin infusion.
C. Administer an analgesic.
D. Reposition the client to the right side.
CORRECT ANSWER: B
Clinical Rationale: This indicates uterine tachysystole (hyperstimulation), which can lead to fetal
distress. The priority is to stop the oxytocin to allow the uterus to rest and improve fetal oxygenation.
(12) A client at 38 weeks gestation presents with sudden, painless, bright red vaginal bleeding.
Which condition should the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Uterine rupture
D. Preterm labor
CORRECT ANSWER: B
Clinical Rationale: Painless, bright red bleeding is the classic sign of placenta previa. Abruptio
placentae usually involves painful, dark red bleeding with uterine rigidity.
