NU171 | NU171 Maternal Child Nursing Exam 2 v2 |
Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is assessing a client at 34 weeks of gestation who has a prescription for
magnesium sulfate to treat preeclampsia. Which of the following findings should the
nurse identify as a manifestation of magnesium toxicity?
A. Respiratory rate of 10/min
B. Hyperreflexia
C. Increased urine output
D. Tachycardia
Correct Answer: A
Expert Explanation: Magnesium sulfate is a central nervous system depressant
used to prevent seizures in preeclampsia. A respiratory rate below 12/min is a
primary sign of magnesium toxicity and requires immediate cessation of the
infusion. The nurse should also monitor for loss of deep tendon reflexes and
decreased urinary output.
,2. A nurse is caring for a client who is in the first stage of labor and has an epidural
block. The nurse notes a blood pressure of 80/40 mmHg. Which of the following
actions should the nurse take first?
A. Place the client in a lateral position
B. Increase the IV fluid rate
C. Administer oxygen via non-rebreather mask
D. Notify the provider immediately
Correct Answer: A
Expert Explanation: Maternal hypotension is a common side effect of epidural
anesthesia due to vasodilation. Placing the client in a lateral position shifts the
uterus off the inferior vena cava, increasing venous return and cardiac output. This
is the first action to improve placental perfusion before escalating interventions.
3. A nurse is teaching a client who is at 12 weeks of gestation about an upcoming
maternal serum alpha-fetoprotein (MSAFP) test. Which of the following statements
should the nurse include?
A. This test checks for fetal lung maturity.
B. This test is diagnostic for Down syndrome.
C. This test determines the sex of the baby.
,D. This test is used to identify neural tube defects.
Correct Answer: D
Expert Explanation: MSAFP is a screening tool used to detect neural tube defects
such as spina bifida and anencephaly. It is typically performed between 15 and 22
weeks of gestation for the most accurate results. High levels of MSAFP are
associated with neural tube defects, while low levels can indicate trisomy 21.
4. A nurse is providing discharge teaching to a client who is postpartum and has a
prescription for Rho(D) immune globulin. Which of the following information should
the nurse include?
A. It is given to Rh-positive mothers to protect the baby.
B. It provides lifelong immunity against Rh sensitization.
C. It is only necessary after the first pregnancy.
D. It should be administered within 72 hours of delivery.
Correct Answer: D
Expert Explanation: Rho(D) immune globulin is administered to Rh-negative
mothers who give birth to Rh-positive infants to prevent sensitization. It must be
given within 72 hours of birth to suppress the maternal immune response to fetal
Rh-positive blood cells. This prevents hemolytic disease of the newborn in
subsequent pregnancies.
, 5. A nurse is caring for a client who is in active labor and notes a late deceleration on
the fetal heart rate monitor. Which of the following is the priority nursing action?
A. Perform a vaginal exam
B. Increase the rate of the oxytocin infusion
C. Administer oxygen at 8 to 10 L/min via mask
D. Encourage the client to use patterned breathing
Correct Answer: C
Expert Explanation: Late decelerations are indicative of uteroplacental
insufficiency and fetal hypoxia. Administering oxygen improves the oxygen
concentration in the maternal blood, which is then transferred to the fetus. The
nurse should also turn the client to their side and discontinue any oxytocin
infusions.
6. A nurse is assessing a newborn 1 hour after birth. Which of the following findings
should the nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. Milia on the bridge of the nose
C. A respiratory rate of 50/min
D. Generalized petechiae over the body
Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is assessing a client at 34 weeks of gestation who has a prescription for
magnesium sulfate to treat preeclampsia. Which of the following findings should the
nurse identify as a manifestation of magnesium toxicity?
A. Respiratory rate of 10/min
B. Hyperreflexia
C. Increased urine output
D. Tachycardia
Correct Answer: A
Expert Explanation: Magnesium sulfate is a central nervous system depressant
used to prevent seizures in preeclampsia. A respiratory rate below 12/min is a
primary sign of magnesium toxicity and requires immediate cessation of the
infusion. The nurse should also monitor for loss of deep tendon reflexes and
decreased urinary output.
,2. A nurse is caring for a client who is in the first stage of labor and has an epidural
block. The nurse notes a blood pressure of 80/40 mmHg. Which of the following
actions should the nurse take first?
A. Place the client in a lateral position
B. Increase the IV fluid rate
C. Administer oxygen via non-rebreather mask
D. Notify the provider immediately
Correct Answer: A
Expert Explanation: Maternal hypotension is a common side effect of epidural
anesthesia due to vasodilation. Placing the client in a lateral position shifts the
uterus off the inferior vena cava, increasing venous return and cardiac output. This
is the first action to improve placental perfusion before escalating interventions.
3. A nurse is teaching a client who is at 12 weeks of gestation about an upcoming
maternal serum alpha-fetoprotein (MSAFP) test. Which of the following statements
should the nurse include?
A. This test checks for fetal lung maturity.
B. This test is diagnostic for Down syndrome.
C. This test determines the sex of the baby.
,D. This test is used to identify neural tube defects.
Correct Answer: D
Expert Explanation: MSAFP is a screening tool used to detect neural tube defects
such as spina bifida and anencephaly. It is typically performed between 15 and 22
weeks of gestation for the most accurate results. High levels of MSAFP are
associated with neural tube defects, while low levels can indicate trisomy 21.
4. A nurse is providing discharge teaching to a client who is postpartum and has a
prescription for Rho(D) immune globulin. Which of the following information should
the nurse include?
A. It is given to Rh-positive mothers to protect the baby.
B. It provides lifelong immunity against Rh sensitization.
C. It is only necessary after the first pregnancy.
D. It should be administered within 72 hours of delivery.
Correct Answer: D
Expert Explanation: Rho(D) immune globulin is administered to Rh-negative
mothers who give birth to Rh-positive infants to prevent sensitization. It must be
given within 72 hours of birth to suppress the maternal immune response to fetal
Rh-positive blood cells. This prevents hemolytic disease of the newborn in
subsequent pregnancies.
, 5. A nurse is caring for a client who is in active labor and notes a late deceleration on
the fetal heart rate monitor. Which of the following is the priority nursing action?
A. Perform a vaginal exam
B. Increase the rate of the oxytocin infusion
C. Administer oxygen at 8 to 10 L/min via mask
D. Encourage the client to use patterned breathing
Correct Answer: C
Expert Explanation: Late decelerations are indicative of uteroplacental
insufficiency and fetal hypoxia. Administering oxygen improves the oxygen
concentration in the maternal blood, which is then transferred to the fetus. The
nurse should also turn the client to their side and discontinue any oxytocin
infusions.
6. A nurse is assessing a newborn 1 hour after birth. Which of the following findings
should the nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. Milia on the bridge of the nose
C. A respiratory rate of 50/min
D. Generalized petechiae over the body
