NU171 | NU171 Maternal Child Nursing Exam 1 v3 |
Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is reviewing the medical record of a client who is at 32 weeks of gestation.
The nurse notes that the client has a GTPAL of 3-1-0-1-1. How should the nurse
interpret this data?
A. The client has had three pregnancies, zero term births, one preterm birth, one
miscarriage, and one living child.
B. The client has had three pregnancies, one term birth, zero preterm births, one
miscarriage, and one living child.
C. The client has had three pregnancies, one term birth, zero preterm births, zero
miscarriages, and one living child.
D. The client has had two pregnancies, one term birth, zero preterm births, one
miscarriage, and one living child.
Correct Answer: B
Expert Explanation: The GTPAL system stands for Gravida, Term, Preterm,
Abortions, and Living children. In this scenario, G3 means three pregnancies, T1
means one term birth (37 weeks or more), P0 means zero preterm births, A1 means
one abortion or miscarriage, and L1 means one living child. This categorization
,helps the healthcare provider understand the client’s complete obstetric history
accurately.
2. A nurse is performing an assessment on a client who is at 38 weeks of gestation and
reports abdominal pain. The nurse notes a board-like abdomen and dark red vaginal
bleeding. Which of the following conditions should the nurse suspect?
A. Placenta previa
B. Hydatidiform mole
C. Preterm labor
D. Abruptio placentae
Correct Answer: D
Expert Explanation: Abruptio placentae is the premature separation of the
placenta from the uterine wall, which often presents with painful, dark red vaginal
bleeding and a rigid, board-like abdomen. In contrast, placenta previa is usually
characterized by painless, bright red bleeding. This condition is a medical
emergency that requires immediate intervention to save both the mother and the
fetus.
3. A nurse is providing teaching to a pregnant client about the importance of folic acid.
The nurse should explain that folic acid helps prevent which of the following?
A. Preeclampsia
,B. Gestational diabetes
C. Neural tube defects
D. Fetal macrosomia
Correct Answer: C
Expert Explanation: Folic acid is a B vitamin that is crucial for the development of
the fetal brain and spinal cord. Adequate intake before and during early pregnancy
significantly reduces the risk of neural tube defects like spina bifida and
anencephaly. The recommended daily intake for most pregnant women is at least
400 to 600 micrograms.
4. A nurse is monitoring a client who is receiving magnesium sulfate via IV infusion for
preeclampsia. Which of the following findings should the nurse report to the provider
as a sign of magnesium toxicity?
A. Respiratory rate of 10 breaths per minute
B. Increased urine output
C. Hyperreflexic deep tendon reflexes
D. Blood pressure of 150/95 mmHg
Correct Answer: A
, Expert Explanation: Magnesium toxicity is a serious complication that can lead to
respiratory depression, which is why a respiratory rate below 12 per minute is a
major warning sign. Other signs include loss of deep tendon reflexes, decreased
urinary output, and cardiac arrest. The nurse must monitor these parameters hourly
while the medication is being administered.
5. A nurse is caring for a client who is in the first stage of labor. The nurse observes a
fetal heart rate (FHR) pattern of early decelerations. Which of the following actions
should the nurse take?
A. Prepare for an immediate cesarean birth
B. Reposition the client to a side-lying position
C. Administer oxygen via nonrebreather mask
D. Continue to monitor the FHR and document the finding
Correct Answer: D
Expert Explanation: Early decelerations are caused by fetal head compression
during contractions and are considered a benign finding. They typically mirror the
contraction and do not indicate fetal distress or hypoxia. Therefore, the nurse
should continue standard monitoring and document the observation without
needing emergency intervention.
Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is reviewing the medical record of a client who is at 32 weeks of gestation.
The nurse notes that the client has a GTPAL of 3-1-0-1-1. How should the nurse
interpret this data?
A. The client has had three pregnancies, zero term births, one preterm birth, one
miscarriage, and one living child.
B. The client has had three pregnancies, one term birth, zero preterm births, one
miscarriage, and one living child.
C. The client has had three pregnancies, one term birth, zero preterm births, zero
miscarriages, and one living child.
D. The client has had two pregnancies, one term birth, zero preterm births, one
miscarriage, and one living child.
Correct Answer: B
Expert Explanation: The GTPAL system stands for Gravida, Term, Preterm,
Abortions, and Living children. In this scenario, G3 means three pregnancies, T1
means one term birth (37 weeks or more), P0 means zero preterm births, A1 means
one abortion or miscarriage, and L1 means one living child. This categorization
,helps the healthcare provider understand the client’s complete obstetric history
accurately.
2. A nurse is performing an assessment on a client who is at 38 weeks of gestation and
reports abdominal pain. The nurse notes a board-like abdomen and dark red vaginal
bleeding. Which of the following conditions should the nurse suspect?
A. Placenta previa
B. Hydatidiform mole
C. Preterm labor
D. Abruptio placentae
Correct Answer: D
Expert Explanation: Abruptio placentae is the premature separation of the
placenta from the uterine wall, which often presents with painful, dark red vaginal
bleeding and a rigid, board-like abdomen. In contrast, placenta previa is usually
characterized by painless, bright red bleeding. This condition is a medical
emergency that requires immediate intervention to save both the mother and the
fetus.
3. A nurse is providing teaching to a pregnant client about the importance of folic acid.
The nurse should explain that folic acid helps prevent which of the following?
A. Preeclampsia
,B. Gestational diabetes
C. Neural tube defects
D. Fetal macrosomia
Correct Answer: C
Expert Explanation: Folic acid is a B vitamin that is crucial for the development of
the fetal brain and spinal cord. Adequate intake before and during early pregnancy
significantly reduces the risk of neural tube defects like spina bifida and
anencephaly. The recommended daily intake for most pregnant women is at least
400 to 600 micrograms.
4. A nurse is monitoring a client who is receiving magnesium sulfate via IV infusion for
preeclampsia. Which of the following findings should the nurse report to the provider
as a sign of magnesium toxicity?
A. Respiratory rate of 10 breaths per minute
B. Increased urine output
C. Hyperreflexic deep tendon reflexes
D. Blood pressure of 150/95 mmHg
Correct Answer: A
, Expert Explanation: Magnesium toxicity is a serious complication that can lead to
respiratory depression, which is why a respiratory rate below 12 per minute is a
major warning sign. Other signs include loss of deep tendon reflexes, decreased
urinary output, and cardiac arrest. The nurse must monitor these parameters hourly
while the medication is being administered.
5. A nurse is caring for a client who is in the first stage of labor. The nurse observes a
fetal heart rate (FHR) pattern of early decelerations. Which of the following actions
should the nurse take?
A. Prepare for an immediate cesarean birth
B. Reposition the client to a side-lying position
C. Administer oxygen via nonrebreather mask
D. Continue to monitor the FHR and document the finding
Correct Answer: D
Expert Explanation: Early decelerations are caused by fetal head compression
during contractions and are considered a benign finding. They typically mirror the
contraction and do not indicate fetal distress or hypoxia. Therefore, the nurse
should continue standard monitoring and document the observation without
needing emergency intervention.
