NU171 | NU171 Maternal Child Nursing Midterm
v3 Questions with Correct Answers and Expert
Explanation for Each Question
1. A nurse is assessing a client who is at 30 weeks of gestation. Which of the following
findings should the nurse report to the provider?
A. Occasional Braxton Hicks contractions
B. Swelling of the face and fingers
C. Increased vaginal discharge
D. Backache when standing for long periods
Correct Answer: B
Expert Explanation: Swelling of the face and fingers can be a sign of preeclampsia
and should be reported immediately. While dependent edema in the lower
extremities is common, facial edema is more concerning. The nurse should monitor
blood pressure and check for protein in the urine if this occurs.
2. A nurse is providing teaching to a client who is pregnant and has a new prescription
for iron supplements. Which of the following instructions should the nurse include?
A. Take the medication with milk to decrease gastric upset.
B. Expect stools to become light green or tan in color.
C. Limit intake of fiber-rich foods while taking the supplement.
,D. Take the medication with orange juice to increase absorption.
Correct Answer: D
Expert Explanation: Vitamin C, found in orange juice, significantly enhances the
absorption of iron. Iron supplements can cause constipation, so increasing fiber
intake is recommended rather than limiting it. It is also expected that stools will
turn black or dark green, not light green.
3. A client at 38 weeks of gestation reports a sudden gush of fluid from the vagina.
What is the priority nursing action?
A. Assess the fetal heart rate.
B. Perform a nitrazine test.
C. Check the maternal temperature.
D. Document the time and amount of fluid.
Correct Answer: A
Expert Explanation: The priority action after the rupture of membranes is to assess
the fetal heart rate to rule out cord prolapse. While testing the fluid with nitrazine
paper confirms rupture, it is secondary to fetal safety. Sudden loss of fluid can cause
the umbilical cord to wash down in front of the fetal head, leading to compression.
,4. A nurse is reviewing the GTPAL for a client who is currently pregnant, has a 3-year-
old child born at 39 weeks, and had a miscarriage at 10 weeks. How should the nurse
document this?
A. G2, T1, P1, A0, L1
B. G2, T1, P0, A1, L1
C. G3, T2, P0, A0, L2
D. G3, T1, P0, A1, L1
Correct Answer: D
Expert Explanation: The client is Gravida 3 because she is currently pregnant, had
one term birth, and one miscarriage. The Term birth (T) is 1, the preterm (P) is 0,
and the abortion/miscarriage (A) is 1. The number of Living children (L) is 1,
representing the 3-year-old child.
5. Which of the following fetal heart rate patterns indicates umbilical cord
compression?
A. Variable decelerations
B. Late decelerations
C. Early decelerations
D. Accelerations
, Correct Answer: A
Expert Explanation: Variable decelerations are typically caused by cord
compression during labor. Early decelerations are caused by head compression and
are generally benign. Late decelerations are caused by uteroplacental insufficiency
and require immediate intervention.
6. A nurse is caring for a client who is in the first stage of labor and has an umbilical
cord prolapse. Which of the following actions should the nurse take first?
A. Prepare the client for an emergency cesarean birth.
B. Place the client in a knee-chest or Trendelenburg position.
C. Apply oxygen via a non-rebreather mask.
D. Increase the rate of the IV fluid infusion.
Correct Answer: B
Expert Explanation: Repositioning the client to knee-chest or Trendelenburg uses
gravity to shift the fetus off the umbilical cord. This action is the priority to restore
fetal oxygenation. Once the pressure is relieved, the nurse should then provide
oxygen and prepare for delivery.
7. A nurse is assessing a newborn 1 hour after birth. Which of the following findings
should the nurse report to the provider?
A. Respiratory rate of 48 breaths per minute
v3 Questions with Correct Answers and Expert
Explanation for Each Question
1. A nurse is assessing a client who is at 30 weeks of gestation. Which of the following
findings should the nurse report to the provider?
A. Occasional Braxton Hicks contractions
B. Swelling of the face and fingers
C. Increased vaginal discharge
D. Backache when standing for long periods
Correct Answer: B
Expert Explanation: Swelling of the face and fingers can be a sign of preeclampsia
and should be reported immediately. While dependent edema in the lower
extremities is common, facial edema is more concerning. The nurse should monitor
blood pressure and check for protein in the urine if this occurs.
2. A nurse is providing teaching to a client who is pregnant and has a new prescription
for iron supplements. Which of the following instructions should the nurse include?
A. Take the medication with milk to decrease gastric upset.
B. Expect stools to become light green or tan in color.
C. Limit intake of fiber-rich foods while taking the supplement.
,D. Take the medication with orange juice to increase absorption.
Correct Answer: D
Expert Explanation: Vitamin C, found in orange juice, significantly enhances the
absorption of iron. Iron supplements can cause constipation, so increasing fiber
intake is recommended rather than limiting it. It is also expected that stools will
turn black or dark green, not light green.
3. A client at 38 weeks of gestation reports a sudden gush of fluid from the vagina.
What is the priority nursing action?
A. Assess the fetal heart rate.
B. Perform a nitrazine test.
C. Check the maternal temperature.
D. Document the time and amount of fluid.
Correct Answer: A
Expert Explanation: The priority action after the rupture of membranes is to assess
the fetal heart rate to rule out cord prolapse. While testing the fluid with nitrazine
paper confirms rupture, it is secondary to fetal safety. Sudden loss of fluid can cause
the umbilical cord to wash down in front of the fetal head, leading to compression.
,4. A nurse is reviewing the GTPAL for a client who is currently pregnant, has a 3-year-
old child born at 39 weeks, and had a miscarriage at 10 weeks. How should the nurse
document this?
A. G2, T1, P1, A0, L1
B. G2, T1, P0, A1, L1
C. G3, T2, P0, A0, L2
D. G3, T1, P0, A1, L1
Correct Answer: D
Expert Explanation: The client is Gravida 3 because she is currently pregnant, had
one term birth, and one miscarriage. The Term birth (T) is 1, the preterm (P) is 0,
and the abortion/miscarriage (A) is 1. The number of Living children (L) is 1,
representing the 3-year-old child.
5. Which of the following fetal heart rate patterns indicates umbilical cord
compression?
A. Variable decelerations
B. Late decelerations
C. Early decelerations
D. Accelerations
, Correct Answer: A
Expert Explanation: Variable decelerations are typically caused by cord
compression during labor. Early decelerations are caused by head compression and
are generally benign. Late decelerations are caused by uteroplacental insufficiency
and require immediate intervention.
6. A nurse is caring for a client who is in the first stage of labor and has an umbilical
cord prolapse. Which of the following actions should the nurse take first?
A. Prepare the client for an emergency cesarean birth.
B. Place the client in a knee-chest or Trendelenburg position.
C. Apply oxygen via a non-rebreather mask.
D. Increase the rate of the IV fluid infusion.
Correct Answer: B
Expert Explanation: Repositioning the client to knee-chest or Trendelenburg uses
gravity to shift the fetus off the umbilical cord. This action is the priority to restore
fetal oxygenation. Once the pressure is relieved, the nurse should then provide
oxygen and prepare for delivery.
7. A nurse is assessing a newborn 1 hour after birth. Which of the following findings
should the nurse report to the provider?
A. Respiratory rate of 48 breaths per minute
