NUR 265 Exam 1-V1 and V2 |
Actual Questions and Answers |
2026 Update | 100% Correct -
Galen College of Nursing.
VERSION 1 (V1)
Question 1
A nurse is assessing a client at 10 weeks gestation. Which finding requires
immediate follow-up?
A) Nausea with vomiting once daily
B) Vaginal bleeding with cramping
C) Leukorrhea
D) Breast tenderness
Correct Answer: B
Rationale: Vaginal bleeding with cramping in the first trimester may indicate spontaneous
abortion (miscarriage), ectopic pregnancy, or other serious complications. Nausea,
leukorrhea, and breast tenderness are expected findings in early pregnancy .
,Question 2
The nurse is teaching a pregnant client about warning signs to report. Which
statement indicates understanding?
A) "It's normal to have visual changes in the third trimester."
B) "I can wait 24 hours to call if I have a headache that won't go away."
C) "I should call if I have sudden swelling in my face and hands."
D) "Leg cramps mean I need more calcium only."
Correct Answer: C
Rationale: Sudden facial and hand swelling with headache may indicate preeclampsia, a
serious complication requiring prompt evaluation. Visual changes, persistent headache,
and edema are danger signs needing immediate reporting .
Question 3
A client is 32 weeks gestation and reports leaking fluid. What is the nurse's priority
action?
A) Perform a vaginal exam to check dilation
B) Test the fluid with nitrazine paper
C) Start an IV of lactated Ringer's
D) Tell client to go home and monitor
Correct Answer: B
Rationale: Suspected preterm premature rupture of membranes (PPROM) requires
confirmation by testing the fluid with nitrazine paper or ferning test. Vaginal exams are
avoided until rupture is ruled out due to infection risk .
Question 4
During labor, the fetal heart rate shows late decelerations. The nurse should FIRST:
,A) Prepare for immediate cesarean delivery
B) Reposition the client to left lateral
C) Administer oxygen at 2 L/min via nasal cannula
D) Document and continue monitoring
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency. The first action is to
reposition the client to the left lateral position to improve uterine blood flow, then
administer oxygen at 8-10 L via non-rebreather, IV fluids, and stop oxytocin if infusing .
Question 5
A postpartum client has a boggy uterus and heavy lochia. What should the nurse
do FIRST?
A) Administer methylergonovine IM
B) Perform fundal massage
C) Assess vital signs
D) Notify the provider
Correct Answer: B
Rationale: A boggy uterus indicates uterine atony, the #1 cause of early postpartum
hemorrhage. Fundal massage is the immediate intervention to promote uterine
contraction and control bleeding, followed by medications, vital signs, and provider
notification .
Question 6
A newborn is 2 hours old. Which finding requires intervention?
A) Acrocyanosis
B) Respiratory rate of 70 with grunting
C) Heart rate 140 bpm
D) Transient head molding
, Correct Answer: B
Rationale: Normal newborn respiratory rate is 30-60 breaths per minute. A rate >60 with
grunting and retractions indicates respiratory distress. Acrocyanosis, HR 120-160, and
molding are normal findings .
Question 7
The nurse is caring for a client with preeclampsia receiving magnesium sulfate.
Which finding indicates toxicity?
A) DTRs 2+
B) Urine output 40 mL/hr
C) Respiratory rate 10/min
D) BP 148/92
Correct Answer: C
Rationale: Magnesium sulfate toxicity signs include loss of deep tendon reflexes (DTRs),
respiratory rate <12, and urine output <30 mL/hr. The antidote is calcium gluconate.
Respiratory depression (RR 10) is a critical finding requiring immediate intervention .
Question 8
A client at 39 weeks is in active labor and requests an epidural. Prior to placement,
the nurse should ensure:
A) Cervix is 8 cm dilated
B) IV fluid bolus is administered
C) Client has voided in last hour
D) Fetal station is +2
Correct Answer: B
Actual Questions and Answers |
2026 Update | 100% Correct -
Galen College of Nursing.
VERSION 1 (V1)
Question 1
A nurse is assessing a client at 10 weeks gestation. Which finding requires
immediate follow-up?
A) Nausea with vomiting once daily
B) Vaginal bleeding with cramping
C) Leukorrhea
D) Breast tenderness
Correct Answer: B
Rationale: Vaginal bleeding with cramping in the first trimester may indicate spontaneous
abortion (miscarriage), ectopic pregnancy, or other serious complications. Nausea,
leukorrhea, and breast tenderness are expected findings in early pregnancy .
,Question 2
The nurse is teaching a pregnant client about warning signs to report. Which
statement indicates understanding?
A) "It's normal to have visual changes in the third trimester."
B) "I can wait 24 hours to call if I have a headache that won't go away."
C) "I should call if I have sudden swelling in my face and hands."
D) "Leg cramps mean I need more calcium only."
Correct Answer: C
Rationale: Sudden facial and hand swelling with headache may indicate preeclampsia, a
serious complication requiring prompt evaluation. Visual changes, persistent headache,
and edema are danger signs needing immediate reporting .
Question 3
A client is 32 weeks gestation and reports leaking fluid. What is the nurse's priority
action?
A) Perform a vaginal exam to check dilation
B) Test the fluid with nitrazine paper
C) Start an IV of lactated Ringer's
D) Tell client to go home and monitor
Correct Answer: B
Rationale: Suspected preterm premature rupture of membranes (PPROM) requires
confirmation by testing the fluid with nitrazine paper or ferning test. Vaginal exams are
avoided until rupture is ruled out due to infection risk .
Question 4
During labor, the fetal heart rate shows late decelerations. The nurse should FIRST:
,A) Prepare for immediate cesarean delivery
B) Reposition the client to left lateral
C) Administer oxygen at 2 L/min via nasal cannula
D) Document and continue monitoring
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency. The first action is to
reposition the client to the left lateral position to improve uterine blood flow, then
administer oxygen at 8-10 L via non-rebreather, IV fluids, and stop oxytocin if infusing .
Question 5
A postpartum client has a boggy uterus and heavy lochia. What should the nurse
do FIRST?
A) Administer methylergonovine IM
B) Perform fundal massage
C) Assess vital signs
D) Notify the provider
Correct Answer: B
Rationale: A boggy uterus indicates uterine atony, the #1 cause of early postpartum
hemorrhage. Fundal massage is the immediate intervention to promote uterine
contraction and control bleeding, followed by medications, vital signs, and provider
notification .
Question 6
A newborn is 2 hours old. Which finding requires intervention?
A) Acrocyanosis
B) Respiratory rate of 70 with grunting
C) Heart rate 140 bpm
D) Transient head molding
, Correct Answer: B
Rationale: Normal newborn respiratory rate is 30-60 breaths per minute. A rate >60 with
grunting and retractions indicates respiratory distress. Acrocyanosis, HR 120-160, and
molding are normal findings .
Question 7
The nurse is caring for a client with preeclampsia receiving magnesium sulfate.
Which finding indicates toxicity?
A) DTRs 2+
B) Urine output 40 mL/hr
C) Respiratory rate 10/min
D) BP 148/92
Correct Answer: C
Rationale: Magnesium sulfate toxicity signs include loss of deep tendon reflexes (DTRs),
respiratory rate <12, and urine output <30 mL/hr. The antidote is calcium gluconate.
Respiratory depression (RR 10) is a critical finding requiring immediate intervention .
Question 8
A client at 39 weeks is in active labor and requests an epidural. Prior to placement,
the nurse should ensure:
A) Cervix is 8 cm dilated
B) IV fluid bolus is administered
C) Client has voided in last hour
D) Fetal station is +2
Correct Answer: B
