NUR 170 Exam 1 Maternal Child Nursing
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1. Practice Questions
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MATERNAL CHILD NURSING EXAM PRACTICE QUESTIONS AND RATIONALES
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The client returns for a follow-up visit and is estimated to be at 20 weeks
gestation. Where does the nurse expect to palpate the fundus?
A. Just above the symphysis pubis
B. Just below the xiphoid process
C. Near the level of the umbilicus
D. Just below the symphysis pubis
Answer: C.
rationale:
The textbook states the fundus extends to the umbilicus between 20 and 22 weeks.
At 20 weeks the fundus is at or near the level of the umbilicus.
Just above the symphysis pubis is where the fundus is palpated at 12 weeks.
Just below the xiphoid process occurs near term around 36 weeks.
Just below the symphysis pubis is not a normal finding at any gestational age.
When the nurse discusses the tasks to be accomplished during the client's
visit at 24 weeks gestation, what test will be performed?
A. Coombs test
B. Glucose tolerance test
C. Papanicolaou (Pap) test
D. Rubella titer
Answer: B.
RATIONALE:
The glucose challenge test (1-hour glucose screen) is routinely performed between
24 and 28 weeks gestation to screen for gestational diabetes. The Pap test and
rubella titer are DONE AT THE FIRST VISIT. The Coombs test screens for Rh
antibodies and is done when Rh incompatibility is a concern — it is not a routine 24-
week test for all clients.
The nurse recognizes which behavior characteristic(s) of women in their first
trimester of pregnancy? (Select all that apply.)
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a. Showing off her sonogram photos
b. Ambivalence about pregnancy
c. Emotional and labile mood
d. Focusing on her infant
e. Fatigue
B, C, E
Rationale:
First trimester is marked by hormonal changes, physical adjustment, and early
psychological adaptation to pregnancy. Common responses include fatigue, mood
shifts, and mixed feelings about the pregnancy.
Rationales for each option:
a. Showing off her sonogram photos Incorrect. This behavior is more common in the
second trimester when pregnancy feels more real and socially shared.
b. Ambivalence about pregnancy Correct. Mixed emotions are common early in
pregnancy as the client adjusts to the news.
c. Emotional and labile mood Correct. Hormonal changes in early pregnancy
contribute to mood swings and emotional sensitivity.
d. Focusing on her infant Incorrect. Fetal attachment and focus typically increase in
the second and third trimesters.
e. Fatigue Correct. High progesterone levels in early pregnancy contribute to
significant fatigue.
The clinic nurse is assisting with an initial prenatal assessment. The following
findings are present: spider nevi on lower legs; dark pink, edematous nasal
mucosa; mild enlargement of the thyroid gland; mottled skin and pallor on
palms and nail beds; heart rate 88 with murmur present. What is the best
action for the nurse to take based on these findings?
A) Document the findings on the prenatal chart.
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B) Have the physician see the client today.
C) Instruct the client to avoid direct sunlight.
D) Analyze previous thyroid hormone lab results.
B) Have the physician see the client today.
rationale: Mottled skin and pallor on the palms and nail beds are warning signs of
poor oxygenation, circulation issues, or anemia. While spider nevi, slightly enlarged
thyroid, and edematous nasal mucosa are expected physiological changes during
pregnancy, signs of hypoxia require immediate medical evaluation.
The combination of mottled skin, pallor on palms and nail beds, and a heart murmur
together could suggest anemia or circulatory compromise requiring evaluation — not
just documentation.
The nurse is seeing prenatal clients in the clinic. Which client is exhibiting
expected findings?
A) 12 weeks' gestation, with fetal heart tones heard by Doppler fetoscope
B) 22 weeks' gestation, client reports no fetal movement felt yet
C) 16 weeks' gestation, fundus three finger-breadths above umbilicus
D) Marked edema
A) 12 weeks' gestation, with fetal heart tones heard by Doppler fetoscope
RATIONALE:
Fetal heart tones are audible by Doppler as early as 8 to 10 weeks and by fetoscope
at 16 to 20 weeks — hearing them at 12 weeks by Doppler is a normal expected
finding.
B is wrong because a client at 22 weeks reporting no movement is concerning —
quickening should have occurred by now even in a primigravida.
C is wrong because at 16 weeks the fundus should be halfway between the
symphysis pubis and the umbilicus — three finger-breadths above the umbilicus is
too high for 16 weeks.