NU 170 Exam 4 Maternal-Child Nursing
(2026/2027) PDF | Nursing | Galen College
1. A nurse is assessing a client at 12 weeks gestation.
Which fundal height finding is expected?
A. At the umbilicus
B. Just above the symphysis pubis
C. At the xiphoid process
D. 2 cm below the umbilicus
Answer: B
Rationale: At 12 weeks, the fundus is usually just above
the symphysis pubis. At 20 weeks, the fundus is at the
umbilicus. At 36 weeks, it reaches the xiphoid process.
2. Which hormone is responsible for maintaining
pregnancy during the first trimester?
A. Estrogen
B. Progesterone
C. Oxytocin
D. Prolactin
1
,Answer: B
Rationale: Progesterone maintains the endometrial lining,
reduces uterine contractility, and supports the pregnancy
until the placenta takes over. Estrogen supports fetal
growth but does not primarily maintain pregnancy.
3. A client at 28 weeks reports painless, bright red
vaginal bleeding. What is the priority action?
A. Perform a digital cervical exam
B. Administer tocolytics
C. Assess fetal heart tones and prepare for ultrasound
D. Send client for a glucose tolerance test
Answer: C
Rationale: Painless bleeding suggests placenta previa.
Digital exam is contraindicated because it can cause
severe hemorrhage. Priority is maternal/fetal assessment
and ultrasound confirmation.
4. Which finding in a pregnant client requires immediate
reporting to the provider?
2
,A. 1+ proteinuria at 30 weeks
B. Blood pressure 110/70 mm Hg
C. Mild ankle edema at 34 weeks
D. Blood pressure 160/110 mm Hg
Answer: D
Rationale: Severe hypertension (≥160/110) can indicate
severe preeclampsia, requiring immediate intervention to
prevent eclampsia, stroke, or placental abruption.
5. A nurse is teaching a client about signs of preterm
labor. Which symptom should the client report?
A. Irregular Braxton Hicks contractions
B. Low back pain that comes and goes
C. Menstrual-like cramping
D. Fetal movement decreasing after a meal
Answer: C
Rationale: Menstrual-like cramping, pelvic pressure, or
lower back pain that is rhythmic can indicate preterm
3
, labor. Braxton Hicks are irregular and do not cause
cervical change.
6. At 36 weeks, a GBS-positive client’s water breaks.
What is the priority intervention?
A. Start IV antibiotics
B. Administer betamethasone
C. Perform vaginal exam every hour
D. Encourage immediate delivery by C-section
Answer: A
Rationale: GBS-positive women with rupture of
membranes should receive intrapartum penicillin to
prevent neonatal GBS sepsis. Betamethasone is for
preterm labor (<34 weeks).
7. Which vaccine is recommended during every
pregnancy (during flu season)?
A. MMR
B. Varicella
4
(2026/2027) PDF | Nursing | Galen College
1. A nurse is assessing a client at 12 weeks gestation.
Which fundal height finding is expected?
A. At the umbilicus
B. Just above the symphysis pubis
C. At the xiphoid process
D. 2 cm below the umbilicus
Answer: B
Rationale: At 12 weeks, the fundus is usually just above
the symphysis pubis. At 20 weeks, the fundus is at the
umbilicus. At 36 weeks, it reaches the xiphoid process.
2. Which hormone is responsible for maintaining
pregnancy during the first trimester?
A. Estrogen
B. Progesterone
C. Oxytocin
D. Prolactin
1
,Answer: B
Rationale: Progesterone maintains the endometrial lining,
reduces uterine contractility, and supports the pregnancy
until the placenta takes over. Estrogen supports fetal
growth but does not primarily maintain pregnancy.
3. A client at 28 weeks reports painless, bright red
vaginal bleeding. What is the priority action?
A. Perform a digital cervical exam
B. Administer tocolytics
C. Assess fetal heart tones and prepare for ultrasound
D. Send client for a glucose tolerance test
Answer: C
Rationale: Painless bleeding suggests placenta previa.
Digital exam is contraindicated because it can cause
severe hemorrhage. Priority is maternal/fetal assessment
and ultrasound confirmation.
4. Which finding in a pregnant client requires immediate
reporting to the provider?
2
,A. 1+ proteinuria at 30 weeks
B. Blood pressure 110/70 mm Hg
C. Mild ankle edema at 34 weeks
D. Blood pressure 160/110 mm Hg
Answer: D
Rationale: Severe hypertension (≥160/110) can indicate
severe preeclampsia, requiring immediate intervention to
prevent eclampsia, stroke, or placental abruption.
5. A nurse is teaching a client about signs of preterm
labor. Which symptom should the client report?
A. Irregular Braxton Hicks contractions
B. Low back pain that comes and goes
C. Menstrual-like cramping
D. Fetal movement decreasing after a meal
Answer: C
Rationale: Menstrual-like cramping, pelvic pressure, or
lower back pain that is rhythmic can indicate preterm
3
, labor. Braxton Hicks are irregular and do not cause
cervical change.
6. At 36 weeks, a GBS-positive client’s water breaks.
What is the priority intervention?
A. Start IV antibiotics
B. Administer betamethasone
C. Perform vaginal exam every hour
D. Encourage immediate delivery by C-section
Answer: A
Rationale: GBS-positive women with rupture of
membranes should receive intrapartum penicillin to
prevent neonatal GBS sepsis. Betamethasone is for
preterm labor (<34 weeks).
7. Which vaccine is recommended during every
pregnancy (during flu season)?
A. MMR
B. Varicella
4
