NU171 | NU171 Maternal Child Nursing Final Exam
v3 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is reviewing a client’s obstetric history: the client is currently 28 weeks
pregnant, had one miscarriage at 10 weeks, and gave birth to one child at 39 weeks.
Using the GTPAL system, how should the nurse document this?
A. G2 T1 P0 A0 L1
B. G3 T1 P0 A1 L1
C. G3 T2 P0 A1 L1
D. G2 T1 P1 A1 L1
Correct Answer: B
Expert Explanation: The client is currently pregnant (G3), has one full-term
delivery (T1), zero preterm deliveries (P0), one abortion/miscarriage (A1), and one
living child (L1). The current pregnancy counts toward Gravida but not yet toward T
or P. Understanding GTPAL is essential for accurate obstetric history assessment
during prenatal visits.
,2. A nurse is caring for a client in the first stage of labor and notes late decelerations
on the fetal heart rate monitor. Which of the following actions should the nurse take
first?
A. Increase the rate of the oxytocin infusion
B. Prepare the client for an immediate vaginal exam
C. Assist the client into a side-lying position
D. Administer oxygen via a non-rebreather mask at 2 L/min
Correct Answer: C
Expert Explanation: Late decelerations are indicative of uteroplacental
insufficiency and require immediate intervention to improve oxygenation.
Repositioning the client to a side-lying position helps relieve pressure on the
inferior vena cava and improves blood flow to the placenta. This is always the
priority nursing action before administering oxygen at higher flows or discontinuing
medications like oxytocin.
3. A client at 32 weeks gestation is admitted with a diagnosis of preeclampsia. Which
of the following findings should the nurse report to the provider immediately?
A. 1+ pitting edema in the lower extremities
B. Blood pressure of 148/92 mmHg
,C. Weight gain of 1 lb in the past week
D. Blurred vision and epigastric pain
Correct Answer: D
Expert Explanation: Blurred vision and epigastric pain are warning signs of
worsening preeclampsia and potential progression to eclampsia or HELLP
syndrome. Epigastric pain often indicates liver involvement or edema of the liver
capsule. The nurse must monitor for these subjective symptoms closely to prevent
seizures and other life-threatening complications.
4. A nurse is assessing a newborn 1 minute after birth and notes the following: heart
rate 110/min, slow/irregular respiratory effort, some flexion of extremities, grimace in
response to suctioning, and a pink body with blue extremities. What is the APGAR
score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
, Expert Explanation: The score is calculated as: HR >100 (2 points), slow/irregular
respirations (1 point), some flexion (1 point), grimace (1 point), and acrocyanosis (1
point), totaling 6. APGAR scores are assessed at 1 and 5 minutes to evaluate the
newborn’s transition to extrauterine life. A score of 6 indicates moderate difficulty
and may require intervention such as stimulation or oxygen.
5. Which of the following medications is the antidote for magnesium sulfate toxicity in
a client being treated for preeclampsia?
A. Naloxone
B. Terbutaline
C. Phytonadione
D. Calcium gluconate
Correct Answer: D
Expert Explanation: Calcium gluconate is the specific antagonist used to reverse
the effects of magnesium toxicity, such as respiratory depression or cardiac arrest.
When administering magnesium sulfate, the nurse must always have calcium
gluconate readily available at the bedside. Close monitoring of deep tendon reflexes
and respiratory rate is required to identify toxicity early.
v3 | Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is reviewing a client’s obstetric history: the client is currently 28 weeks
pregnant, had one miscarriage at 10 weeks, and gave birth to one child at 39 weeks.
Using the GTPAL system, how should the nurse document this?
A. G2 T1 P0 A0 L1
B. G3 T1 P0 A1 L1
C. G3 T2 P0 A1 L1
D. G2 T1 P1 A1 L1
Correct Answer: B
Expert Explanation: The client is currently pregnant (G3), has one full-term
delivery (T1), zero preterm deliveries (P0), one abortion/miscarriage (A1), and one
living child (L1). The current pregnancy counts toward Gravida but not yet toward T
or P. Understanding GTPAL is essential for accurate obstetric history assessment
during prenatal visits.
,2. A nurse is caring for a client in the first stage of labor and notes late decelerations
on the fetal heart rate monitor. Which of the following actions should the nurse take
first?
A. Increase the rate of the oxytocin infusion
B. Prepare the client for an immediate vaginal exam
C. Assist the client into a side-lying position
D. Administer oxygen via a non-rebreather mask at 2 L/min
Correct Answer: C
Expert Explanation: Late decelerations are indicative of uteroplacental
insufficiency and require immediate intervention to improve oxygenation.
Repositioning the client to a side-lying position helps relieve pressure on the
inferior vena cava and improves blood flow to the placenta. This is always the
priority nursing action before administering oxygen at higher flows or discontinuing
medications like oxytocin.
3. A client at 32 weeks gestation is admitted with a diagnosis of preeclampsia. Which
of the following findings should the nurse report to the provider immediately?
A. 1+ pitting edema in the lower extremities
B. Blood pressure of 148/92 mmHg
,C. Weight gain of 1 lb in the past week
D. Blurred vision and epigastric pain
Correct Answer: D
Expert Explanation: Blurred vision and epigastric pain are warning signs of
worsening preeclampsia and potential progression to eclampsia or HELLP
syndrome. Epigastric pain often indicates liver involvement or edema of the liver
capsule. The nurse must monitor for these subjective symptoms closely to prevent
seizures and other life-threatening complications.
4. A nurse is assessing a newborn 1 minute after birth and notes the following: heart
rate 110/min, slow/irregular respiratory effort, some flexion of extremities, grimace in
response to suctioning, and a pink body with blue extremities. What is the APGAR
score?
A. 5
B. 6
C. 7
D. 8
Correct Answer: B
, Expert Explanation: The score is calculated as: HR >100 (2 points), slow/irregular
respirations (1 point), some flexion (1 point), grimace (1 point), and acrocyanosis (1
point), totaling 6. APGAR scores are assessed at 1 and 5 minutes to evaluate the
newborn’s transition to extrauterine life. A score of 6 indicates moderate difficulty
and may require intervention such as stimulation or oxygen.
5. Which of the following medications is the antidote for magnesium sulfate toxicity in
a client being treated for preeclampsia?
A. Naloxone
B. Terbutaline
C. Phytonadione
D. Calcium gluconate
Correct Answer: D
Expert Explanation: Calcium gluconate is the specific antagonist used to reverse
the effects of magnesium toxicity, such as respiratory depression or cardiac arrest.
When administering magnesium sulfate, the nurse must always have calcium
gluconate readily available at the bedside. Close monitoring of deep tendon reflexes
and respiratory rate is required to identify toxicity early.
