NUR 230 Exam 1 V2 | NUR 230 The
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 1) | Galen
College of Nursing
1. A nurse is assessing a client who is at 12 weeks of gestation and has a body mass index
(BMI) of 22. What is the total recommended weight gain for this client during pregnancy?
A. 11 to 20 lbs
B. 25 to 35 lbs
C. 15 to 25 lbs
D. 28 to 40 lbs
Answer: B
Rationale: A client with a normal BMI of 18.5 to 24.9 should ideally gain 25 to 35 lbs
throughout the pregnancy. Gaining insufficient weight can lead to low birth weight for the
infant. Conversely, excessive gain increases the risk for gestational diabetes and cesarean
delivery.
2. Which of the following physiological changes is considered a positive sign of pregnancy?
A. Amenorrhea
B. Chadwick’s sign
C. Fetal heart tones heard via Doppler
,D. Positive serum pregnancy test
Answer: C
Rationale: Positive signs of pregnancy are those that can only be attributed to the
presence of a fetus. These include hearing fetal heart sounds, visualizing the fetus via
ultrasound, and palpating fetal movement by an examiner. Amenorrhea is a presumptive
sign, while Chadwick’s sign and pregnancy tests are probable signs.
3. A pregnant client informs the nurse that her last menstrual period (LMP) began on June
10th. Using Naegele’s rule, what is her estimated date of birth (EDB)?
A. March 17th
B. March 3rd
C. March 7th
D. April 17th
Answer: A
Rationale: To calculate the EDB using Naegele’s rule, the nurse should subtract 3 months
from the first day of the LMP and add 7 days and 1 year. Subtracting 3 months from June
10th results in March 10th, and adding 7 days results in March 17th. This method assumes
a standard 28-day menstrual cycle.
4. A nurse is teaching a client about the purpose of the Alpha-fetoprotein (AFP) screening.
Which statement by the nurse is correct?
A. It confirms the presence of trisomy 21.
, B. It identifies the sex of the fetus.
C. It is a screening tool for neural tube defects.
D. It measures the maturity of the fetal lungs.
Answer: C
Rationale: AFP is a protein produced by the fetal liver and found in maternal serum. High
levels may indicate neural tube defects like spina bifida, while low levels can be associated
with chromosomal abnormalities like Down syndrome. It is important to remember this is
a screening test, not a diagnostic one, requiring further follow-up if abnormal.
5. Which of the following is the priority nursing action for a client exhibiting late
decelerations on the fetal monitor?
A. Increase the rate of Pitocin infusion.
B. Administer oxygen via nonrebreather mask at 8-10 L/min.
C. Assist the client into a supine position.
D. Perform a vaginal exam to check for cord prolapse.
Answer: B
Rationale: Late decelerations are caused by uteroplacental insufficiency, which reduces
oxygen delivery to the fetus. The nurse must prioritize intrauterine resuscitation, which
includes repositioning the client to a side-lying position, increasing IV fluids, and
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 1) | Galen
College of Nursing
1. A nurse is assessing a client who is at 12 weeks of gestation and has a body mass index
(BMI) of 22. What is the total recommended weight gain for this client during pregnancy?
A. 11 to 20 lbs
B. 25 to 35 lbs
C. 15 to 25 lbs
D. 28 to 40 lbs
Answer: B
Rationale: A client with a normal BMI of 18.5 to 24.9 should ideally gain 25 to 35 lbs
throughout the pregnancy. Gaining insufficient weight can lead to low birth weight for the
infant. Conversely, excessive gain increases the risk for gestational diabetes and cesarean
delivery.
2. Which of the following physiological changes is considered a positive sign of pregnancy?
A. Amenorrhea
B. Chadwick’s sign
C. Fetal heart tones heard via Doppler
,D. Positive serum pregnancy test
Answer: C
Rationale: Positive signs of pregnancy are those that can only be attributed to the
presence of a fetus. These include hearing fetal heart sounds, visualizing the fetus via
ultrasound, and palpating fetal movement by an examiner. Amenorrhea is a presumptive
sign, while Chadwick’s sign and pregnancy tests are probable signs.
3. A pregnant client informs the nurse that her last menstrual period (LMP) began on June
10th. Using Naegele’s rule, what is her estimated date of birth (EDB)?
A. March 17th
B. March 3rd
C. March 7th
D. April 17th
Answer: A
Rationale: To calculate the EDB using Naegele’s rule, the nurse should subtract 3 months
from the first day of the LMP and add 7 days and 1 year. Subtracting 3 months from June
10th results in March 10th, and adding 7 days results in March 17th. This method assumes
a standard 28-day menstrual cycle.
4. A nurse is teaching a client about the purpose of the Alpha-fetoprotein (AFP) screening.
Which statement by the nurse is correct?
A. It confirms the presence of trisomy 21.
, B. It identifies the sex of the fetus.
C. It is a screening tool for neural tube defects.
D. It measures the maturity of the fetal lungs.
Answer: C
Rationale: AFP is a protein produced by the fetal liver and found in maternal serum. High
levels may indicate neural tube defects like spina bifida, while low levels can be associated
with chromosomal abnormalities like Down syndrome. It is important to remember this is
a screening test, not a diagnostic one, requiring further follow-up if abnormal.
5. Which of the following is the priority nursing action for a client exhibiting late
decelerations on the fetal monitor?
A. Increase the rate of Pitocin infusion.
B. Administer oxygen via nonrebreather mask at 8-10 L/min.
C. Assist the client into a supine position.
D. Perform a vaginal exam to check for cord prolapse.
Answer: B
Rationale: Late decelerations are caused by uteroplacental insufficiency, which reduces
oxygen delivery to the fetus. The nurse must prioritize intrauterine resuscitation, which
includes repositioning the client to a side-lying position, increasing IV fluids, and
