NUR 231 Exam 2: Childbearing and Child Caring Family 2026 Galen
College
1. A nurse is monitoring a client who is receiving magnesium sulfate for
preeclampsia. Which of the following findings should the nurse identify as a sign
of magnesium toxicity?
A. Increased urine output
B. Deep tendon reflexes of 2+
C. Blood pressure of 140/90 mmHg
D. Respiratory rate of 10/min
Answer: D
Rationale: A respiratory rate below 12/min is a primary sign of magnesium sulfate
toxicity. Other signs include loss of deep tendon reflexes and decreased urine output.
2. A nurse is caring for a client in labor and observes a fetal heart rate (FHR)
pattern showing late decelerations. Which of the following actions should the
nurse take first?
A. Increase the oxytocin infusion rate
B. Administer oxygen via nasal cannula at 2 L/min
C. Perform a vaginal exam
D. Assist the client into a side-lying position
Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency. The priority is to
improve oxygenation to the fetus by positioning the mother on her side to increase blood
flow.
,3. A client at 34 weeks of gestation presents with painless, bright red vaginal
bleeding. The nurse should suspect which of the following conditions?
A. Abruptio placentae
B. Ectopic pregnancy
C. Placenta previa
D. Ruptured uterus
Answer: C
Rationale: Placenta previa is typically characterized by painless, bright red bleeding in the
third trimester. Abruptio placentae usually involves painful, dark red bleeding.
4. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart
rate of 110/min, a weak cry, some flexion of extremities, grimaces when flicked
on the sole, and a pink body with blue extremities. What is the Apgar score?
A. 5
B. 6
C. 7
D. 8
Answer: B
Rationale: Heart rate (2), Respiratory effort (1), Muscle tone (1), Reflex irritability (1),
Color (1). Total = 6.
5. A nurse is teaching a client about Rho(D) immune globulin (RhoGAM). In
which of the following situations is RhoGAM indicated?
A. An Rh-positive mother with an Rh-negative newborn
B. An Rh-negative mother with an Rh-negative newborn
C. An Rh-negative mother with an Rh-positive newborn
D. An Rh-positive mother with an Rh-positive newborn
Answer: C
, Rationale: RhoGAM is administered to Rh-negative mothers who give birth to Rh-positive
babies to prevent sensitization to the Rh factor.
6. A client is in the first stage of labor and is 6 cm dilated. The nurse notes the
fetus is at -2 station. Where is the presenting part located?
A. 2 cm above the ischial spines
B. 2 cm below the ischial spines
C. Level with the ischial spines
D. At the pelvic inlet
Answer: A
Rationale: Negative station numbers indicate the presenting part is above the level of the
ischial spines.
7. Which of the following medications is used to stimulate fetal lung maturity in
a client experiencing preterm labor?
A. Nifedipine
B. Betamethasone
C. Terbutaline
D. Indomethacin
Answer: B
Rationale: Betamethasone is a glucocorticoid administered to clients in preterm labor to
promote fetal lung surfactant production.
College
1. A nurse is monitoring a client who is receiving magnesium sulfate for
preeclampsia. Which of the following findings should the nurse identify as a sign
of magnesium toxicity?
A. Increased urine output
B. Deep tendon reflexes of 2+
C. Blood pressure of 140/90 mmHg
D. Respiratory rate of 10/min
Answer: D
Rationale: A respiratory rate below 12/min is a primary sign of magnesium sulfate
toxicity. Other signs include loss of deep tendon reflexes and decreased urine output.
2. A nurse is caring for a client in labor and observes a fetal heart rate (FHR)
pattern showing late decelerations. Which of the following actions should the
nurse take first?
A. Increase the oxytocin infusion rate
B. Administer oxygen via nasal cannula at 2 L/min
C. Perform a vaginal exam
D. Assist the client into a side-lying position
Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency. The priority is to
improve oxygenation to the fetus by positioning the mother on her side to increase blood
flow.
,3. A client at 34 weeks of gestation presents with painless, bright red vaginal
bleeding. The nurse should suspect which of the following conditions?
A. Abruptio placentae
B. Ectopic pregnancy
C. Placenta previa
D. Ruptured uterus
Answer: C
Rationale: Placenta previa is typically characterized by painless, bright red bleeding in the
third trimester. Abruptio placentae usually involves painful, dark red bleeding.
4. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart
rate of 110/min, a weak cry, some flexion of extremities, grimaces when flicked
on the sole, and a pink body with blue extremities. What is the Apgar score?
A. 5
B. 6
C. 7
D. 8
Answer: B
Rationale: Heart rate (2), Respiratory effort (1), Muscle tone (1), Reflex irritability (1),
Color (1). Total = 6.
5. A nurse is teaching a client about Rho(D) immune globulin (RhoGAM). In
which of the following situations is RhoGAM indicated?
A. An Rh-positive mother with an Rh-negative newborn
B. An Rh-negative mother with an Rh-negative newborn
C. An Rh-negative mother with an Rh-positive newborn
D. An Rh-positive mother with an Rh-positive newborn
Answer: C
, Rationale: RhoGAM is administered to Rh-negative mothers who give birth to Rh-positive
babies to prevent sensitization to the Rh factor.
6. A client is in the first stage of labor and is 6 cm dilated. The nurse notes the
fetus is at -2 station. Where is the presenting part located?
A. 2 cm above the ischial spines
B. 2 cm below the ischial spines
C. Level with the ischial spines
D. At the pelvic inlet
Answer: A
Rationale: Negative station numbers indicate the presenting part is above the level of the
ischial spines.
7. Which of the following medications is used to stimulate fetal lung maturity in
a client experiencing preterm labor?
A. Nifedipine
B. Betamethasone
C. Terbutaline
D. Indomethacin
Answer: B
Rationale: Betamethasone is a glucocorticoid administered to clients in preterm labor to
promote fetal lung surfactant production.
