NU171 | NU171 Maternal Child Nursing Exam 2 v1 |
Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a client who is in active labor and notes late decelerations on
the fetal monitor. What is the priority nursing action?
A. Turn the client onto her left side
B. Increase the rate of the IV infusion
C. Administer oxygen via a nonrebreather mask
D. Perform a vaginal examination to check for cord prolapse
Correct Answer: A
Expert Explanation: Late decelerations are indicative of uteroplacental
insufficiency, which can lead to fetal hypoxia. Turning the client to the left side
improves uterine blood flow and oxygenation to the fetus. This is the first step in
intrauterine resuscitation before increasing fluids or giving oxygen.
2. Which of the following assessments is a priority for a client receiving magnesium
sulfate for preeclampsia?
A. Assessing for facial edema
B. Checking blood glucose levels
C. Monitoring hourly urine output
,D. Measuring head circumference
Correct Answer: C
Expert Explanation: Magnesium sulfate is excreted by the kidneys, so monitoring
urine output is critical to prevent toxicity. If output drops below 30 mL/hr,
magnesium can build up to dangerous levels in the blood. The nurse must also
monitor deep tendon reflexes and respiratory rate to ensure safe administration.
3. A postpartum nurse is assessing a client 2 hours after delivery and finds the fundus
to be boggy and displaced to the right. What should the nurse do first?
A. Administer oxytocin as prescribed
B. Massage the fundus until firm
C. Notify the primary healthcare provider
D. Ask the client to void or catheterize her
Correct Answer: D
Expert Explanation: A fundus that is displaced to the right and boggy typically
indicates a distended bladder. A full bladder prevents the uterus from contracting
efficiently, increasing the risk of postpartum hemorrhage. Emptying the bladder is
the priority intervention to allow the uterus to return to the midline and contract.
,4. Which sign observed in a newborn should be reported to the provider immediately?
A. Acrocyanosis in the hands and feet
B. Nasal flaring and chest retractions
C. Milia on the nose and chin
D. Occasional sneezing
Correct Answer: B
Expert Explanation: Nasal flaring and chest retractions are classic signs of
respiratory distress in a newborn and require immediate intervention. Acrocyanosis
is a normal finding in the first 24 to 48 hours of life. Milia and sneezing are also
normal physiological findings for a neonate.
5. A nurse is teaching a mother about breastfeeding. Which statement by the mother
indicates an understanding of the teaching?
A. I will use a clock to time feedings to 10 minutes per side
B. I will ensure the baby’s mouth covers most of the areola
C. I should hear a clicking sound when the baby is sucking
D. I will wait for my baby to cry before offering the breast
Correct Answer: B
, Expert Explanation: A proper latch is achieved when the baby’s mouth covers most
of the areola and the lips are flanged out. Feeding should be based on infant cues,
not a strict schedule or waiting for crying, which is a late sign of hunger. A clicking
sound often indicates a poor latch or shallow suck.
6. What is the primary purpose of administering Rho(D) immune globulin (RhoGAM)
to an Rh-negative mother?
A. To treat jaundice in the newborn
B. To prevent maternal sensitization to Rh-positive fetal blood
C. To increase the maternal white blood cell count
D. To stimulate fetal lung maturity
Correct Answer: B
Expert Explanation: RhoGAM is administered to Rh-negative mothers to prevent
the development of antibodies against Rh-positive fetal blood. This prevents
hemolytic disease of the newborn in future pregnancies. It is typically given at 28
weeks gestation and within 72 hours of delivery if the infant is Rh-positive.
7. A nurse is preparing to administer erythromycin ophthalmic ointment to a
newborn. Why is this medication given?
A. To prevent neonatal blindness from gonorrhea or chlamydia
B. To reduce the risk of cataracts later in life
Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a client who is in active labor and notes late decelerations on
the fetal monitor. What is the priority nursing action?
A. Turn the client onto her left side
B. Increase the rate of the IV infusion
C. Administer oxygen via a nonrebreather mask
D. Perform a vaginal examination to check for cord prolapse
Correct Answer: A
Expert Explanation: Late decelerations are indicative of uteroplacental
insufficiency, which can lead to fetal hypoxia. Turning the client to the left side
improves uterine blood flow and oxygenation to the fetus. This is the first step in
intrauterine resuscitation before increasing fluids or giving oxygen.
2. Which of the following assessments is a priority for a client receiving magnesium
sulfate for preeclampsia?
A. Assessing for facial edema
B. Checking blood glucose levels
C. Monitoring hourly urine output
,D. Measuring head circumference
Correct Answer: C
Expert Explanation: Magnesium sulfate is excreted by the kidneys, so monitoring
urine output is critical to prevent toxicity. If output drops below 30 mL/hr,
magnesium can build up to dangerous levels in the blood. The nurse must also
monitor deep tendon reflexes and respiratory rate to ensure safe administration.
3. A postpartum nurse is assessing a client 2 hours after delivery and finds the fundus
to be boggy and displaced to the right. What should the nurse do first?
A. Administer oxytocin as prescribed
B. Massage the fundus until firm
C. Notify the primary healthcare provider
D. Ask the client to void or catheterize her
Correct Answer: D
Expert Explanation: A fundus that is displaced to the right and boggy typically
indicates a distended bladder. A full bladder prevents the uterus from contracting
efficiently, increasing the risk of postpartum hemorrhage. Emptying the bladder is
the priority intervention to allow the uterus to return to the midline and contract.
,4. Which sign observed in a newborn should be reported to the provider immediately?
A. Acrocyanosis in the hands and feet
B. Nasal flaring and chest retractions
C. Milia on the nose and chin
D. Occasional sneezing
Correct Answer: B
Expert Explanation: Nasal flaring and chest retractions are classic signs of
respiratory distress in a newborn and require immediate intervention. Acrocyanosis
is a normal finding in the first 24 to 48 hours of life. Milia and sneezing are also
normal physiological findings for a neonate.
5. A nurse is teaching a mother about breastfeeding. Which statement by the mother
indicates an understanding of the teaching?
A. I will use a clock to time feedings to 10 minutes per side
B. I will ensure the baby’s mouth covers most of the areola
C. I should hear a clicking sound when the baby is sucking
D. I will wait for my baby to cry before offering the breast
Correct Answer: B
, Expert Explanation: A proper latch is achieved when the baby’s mouth covers most
of the areola and the lips are flanged out. Feeding should be based on infant cues,
not a strict schedule or waiting for crying, which is a late sign of hunger. A clicking
sound often indicates a poor latch or shallow suck.
6. What is the primary purpose of administering Rho(D) immune globulin (RhoGAM)
to an Rh-negative mother?
A. To treat jaundice in the newborn
B. To prevent maternal sensitization to Rh-positive fetal blood
C. To increase the maternal white blood cell count
D. To stimulate fetal lung maturity
Correct Answer: B
Expert Explanation: RhoGAM is administered to Rh-negative mothers to prevent
the development of antibodies against Rh-positive fetal blood. This prevents
hemolytic disease of the newborn in future pregnancies. It is typically given at 28
weeks gestation and within 72 hours of delivery if the infant is Rh-positive.
7. A nurse is preparing to administer erythromycin ophthalmic ointment to a
newborn. Why is this medication given?
A. To prevent neonatal blindness from gonorrhea or chlamydia
B. To reduce the risk of cataracts later in life
