NU171 | NU171 Maternal Child Nursing Exam 2 v3 |
Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a patient in the transition phase of the first stage of labor. The
patient reports a strong urge to push. What is the most appropriate nursing action?
A. Encourage the patient to push with the next contraction.
B. Assist the patient into a lithotomy position.
C. Administer an analgesic for pain management.
D. Perform a vaginal exam to assess cervical dilation.
Correct Answer: D
Expert Explanation: The transition phase occurs when the cervix is dilated 8 to 10
cm. If a patient feels the urge to push, the nurse must first verify if they are fully
dilated to avoid cervical trauma or swelling. Pushing against an undilated cervix can
cause significant complications for the mother.
2. A nurse is monitoring a fetal heart rate (FHR) tracing and notes repetitive early
decelerations. Which of the following is the cause of this pattern?
A. Fetal head compression
B. Umbilical cord compression
C. Uteroplacental insufficiency
,D. Fetal hypoxia
Correct Answer: A
Expert Explanation: Early decelerations are a normal finding during labor and are
typically caused by fetal head compression. They mirror the contraction, meaning
they start when the contraction begins and end when the contraction ends. No
clinical intervention is usually required other than continued monitoring.
3. Which of the following medications is most commonly used to prevent seizures in a
patient with preeclampsia?
A. Nifedipine
B. Hydralazine
C. Magnesium Sulfate
D. Terbutaline
Correct Answer: C
Expert Explanation: Magnesium Sulfate is the gold standard for seizure
prophylaxis in patients diagnosed with preeclampsia or eclampsia. It acts as a
central nervous system depressant to prevent the onset of eclamptic seizures. The
nurse must monitor for toxicity by checking deep tendon reflexes and respiratory
rate.
,4. A postpartum nurse is assessing a mother 2 hours after delivery. The fundus is
noted to be boggy and shifted to the right of the midline. What is the priority nursing
action?
A. Massage the fundus until firm.
B. Call the healthcare provider immediately.
C. Assess the patient for signs of infection.
D. Encourage the patient to empty her bladder.
Correct Answer: D
Expert Explanation: A fundus that is displaced to the right usually indicates a full
bladder, which prevents the uterus from contracting effectively. Assisting the
patient to void will allow the uterus to return to the midline and firm up. If the
fundus remains boggy after voiding, then fundal massage should be the next step.
5. Which APGAR score component evaluates the newborn’s muscle tone?
A. Appearance
B. Activity
C. Grimace
D. Pulse
Correct Answer: B
, Expert Explanation: The APGAR acronym stands for Appearance, Pulse, Grimace,
Activity, and Respiration. Activity specifically measures the degree of flexion and
movement in the newborn’s limbs. A score of 2 is given for well-flexed extremities
that resist extension.
6. A nurse is caring for a client who is receiving an oxytocin infusion for labor
induction. The nurse notes contractions occur every 90 seconds and last 100 seconds.
What is the nurse’s priority action?
A. Increase the oxytocin infusion rate.
B. Discontinue the oxytocin infusion.
C. Notify the provider to request an epidural.
D. Check the maternal blood pressure.
Correct Answer: B
Expert Explanation: The client is experiencing uterine tachysystole, which can lead
to fetal distress and decreased placental perfusion. Discontinuing the oxytocin is the
immediate priority to allow the uterus to rest. The nurse should also monitor fetal
heart rate and provide oxygen if necessary.
Questions with Correct Answers and Expert
Explanation for Each Question | Galen
1. A nurse is caring for a patient in the transition phase of the first stage of labor. The
patient reports a strong urge to push. What is the most appropriate nursing action?
A. Encourage the patient to push with the next contraction.
B. Assist the patient into a lithotomy position.
C. Administer an analgesic for pain management.
D. Perform a vaginal exam to assess cervical dilation.
Correct Answer: D
Expert Explanation: The transition phase occurs when the cervix is dilated 8 to 10
cm. If a patient feels the urge to push, the nurse must first verify if they are fully
dilated to avoid cervical trauma or swelling. Pushing against an undilated cervix can
cause significant complications for the mother.
2. A nurse is monitoring a fetal heart rate (FHR) tracing and notes repetitive early
decelerations. Which of the following is the cause of this pattern?
A. Fetal head compression
B. Umbilical cord compression
C. Uteroplacental insufficiency
,D. Fetal hypoxia
Correct Answer: A
Expert Explanation: Early decelerations are a normal finding during labor and are
typically caused by fetal head compression. They mirror the contraction, meaning
they start when the contraction begins and end when the contraction ends. No
clinical intervention is usually required other than continued monitoring.
3. Which of the following medications is most commonly used to prevent seizures in a
patient with preeclampsia?
A. Nifedipine
B. Hydralazine
C. Magnesium Sulfate
D. Terbutaline
Correct Answer: C
Expert Explanation: Magnesium Sulfate is the gold standard for seizure
prophylaxis in patients diagnosed with preeclampsia or eclampsia. It acts as a
central nervous system depressant to prevent the onset of eclamptic seizures. The
nurse must monitor for toxicity by checking deep tendon reflexes and respiratory
rate.
,4. A postpartum nurse is assessing a mother 2 hours after delivery. The fundus is
noted to be boggy and shifted to the right of the midline. What is the priority nursing
action?
A. Massage the fundus until firm.
B. Call the healthcare provider immediately.
C. Assess the patient for signs of infection.
D. Encourage the patient to empty her bladder.
Correct Answer: D
Expert Explanation: A fundus that is displaced to the right usually indicates a full
bladder, which prevents the uterus from contracting effectively. Assisting the
patient to void will allow the uterus to return to the midline and firm up. If the
fundus remains boggy after voiding, then fundal massage should be the next step.
5. Which APGAR score component evaluates the newborn’s muscle tone?
A. Appearance
B. Activity
C. Grimace
D. Pulse
Correct Answer: B
, Expert Explanation: The APGAR acronym stands for Appearance, Pulse, Grimace,
Activity, and Respiration. Activity specifically measures the degree of flexion and
movement in the newborn’s limbs. A score of 2 is given for well-flexed extremities
that resist extension.
6. A nurse is caring for a client who is receiving an oxytocin infusion for labor
induction. The nurse notes contractions occur every 90 seconds and last 100 seconds.
What is the nurse’s priority action?
A. Increase the oxytocin infusion rate.
B. Discontinue the oxytocin infusion.
C. Notify the provider to request an epidural.
D. Check the maternal blood pressure.
Correct Answer: B
Expert Explanation: The client is experiencing uterine tachysystole, which can lead
to fetal distress and decreased placental perfusion. Discontinuing the oxytocin is the
immediate priority to allow the uterus to rest. The nurse should also monitor fetal
heart rate and provide oxygen if necessary.
