NSG 432 Exam 2 V1 | NSG 432 Nursing
Care of the Childbearing Family | Actual
Q&A with Rationale (NSG432 Exam 2) |
Grand Canyon University
1. A nurse is assessing a newborn at 1 minute after birth. Which of the following parameters
are included in the APGAR scoring system? (Select all that apply)
A. Heart rate
B. Respiratory effort
C. Muscle tone
D. Reflex irritability
E. Skin color
F. Blood pressure
Correct Answer: A,B,C,D,E
Explanation: The APGAR scoring system evaluates five specific categories to determine the
newborn’s immediate adjustment to extrauterine life. These categories include heart rate,
respiratory effort, muscle tone, reflex irritability, and color, each scored from 0 to 2. Blood
pressure is not included in the APGAR score because it is not a primary indicator of
immediate neonatal transition and is difficult to measure accurately in the first minutes.
,2. A client in the active phase of labor presents with a fetal heart rate (FHR) tracing showing
late decelerations. Which of the following is the priority nursing action?
A. Administer oxygen via non-rebreather mask at 10 L/min.
B. Perform a vaginal exam to check for cord prolapse.
C. Increase the rate of the maintenance IV fluids.
D. Position the client in a side-lying lateral position.
Correct Answer: D
Explanation: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intervention to improve oxygenation. The first and most effective step is to
reposition the client to her side to remove pressure from the inferior vena cava and
improve blood flow. Other interventions like oxygen and IV fluids should follow once the
position is changed.
3. The nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. Which
findings would indicate magnesium toxicity? (Select all that apply)
A. Absent deep tendon reflexes
B. Respiratory rate of 10 breaths/min
C. Urinary output of 50 mL/hr
D. Decreased level of consciousness
E. Fetal tachycardia
,Correct Answer: A,B,D
Explanation: Magnesium sulfate is a central nervous system depressant, and toxicity can
lead to life-threatening complications. Classic signs of toxicity include the loss of deep
tendon reflexes, respiratory depression (less than 12 breaths/min), and altered mental
status or lethargy. While low urinary output can lead to toxicity, 50 mL/hr is considered
adequate; however, anything less than 30 mL/hr would be concerning for magnesium
accumulation.
4. During a vaginal examination, the nurse notes that the umbilical cord is protruding from
the vagina. What is the immediate priority action?
A. Place the client in a Trendelenburg or knee-chest position.
B. Apply a warm, saline-soaked gauze to the cord.
C. Attempt to push the cord back into the uterus.
D. Call the healthcare provider to schedule a vacuum extraction.
Correct Answer: A
Explanation: A prolapsed umbilical cord is a medical emergency because the presenting
part can compress the cord, cutting off fetal oxygen. Placing the mother in a Trendelenburg
or knee-chest position uses gravity to shift the fetus off the cord. The nurse should also
maintain manual upward pressure on the presenting part until a cesarean section can be
performed.
, 5. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Placenta previa
B. Placental abruption
C. Preterm labor
D. Ruptured uterus
Correct Answer: A
Explanation: Painless, bright red vaginal bleeding in the second or third trimester is a
hallmark sign of placenta previa, where the placenta covers the cervical os. In contrast,
placental abruption typically presents with painful, dark red bleeding and uterine rigidity.
It is critical to avoid vaginal exams in these clients until the placental location is confirmed
by ultrasound.
6. A nurse is monitoring a client in labor who is dilated to 9 cm and expresses a strong urge to
push. The nurse should recognize this as which phase of labor?
A. Transition phase
B. Active phase
C. Latent phase
D. Second stage
Correct Answer: A
Care of the Childbearing Family | Actual
Q&A with Rationale (NSG432 Exam 2) |
Grand Canyon University
1. A nurse is assessing a newborn at 1 minute after birth. Which of the following parameters
are included in the APGAR scoring system? (Select all that apply)
A. Heart rate
B. Respiratory effort
C. Muscle tone
D. Reflex irritability
E. Skin color
F. Blood pressure
Correct Answer: A,B,C,D,E
Explanation: The APGAR scoring system evaluates five specific categories to determine the
newborn’s immediate adjustment to extrauterine life. These categories include heart rate,
respiratory effort, muscle tone, reflex irritability, and color, each scored from 0 to 2. Blood
pressure is not included in the APGAR score because it is not a primary indicator of
immediate neonatal transition and is difficult to measure accurately in the first minutes.
,2. A client in the active phase of labor presents with a fetal heart rate (FHR) tracing showing
late decelerations. Which of the following is the priority nursing action?
A. Administer oxygen via non-rebreather mask at 10 L/min.
B. Perform a vaginal exam to check for cord prolapse.
C. Increase the rate of the maintenance IV fluids.
D. Position the client in a side-lying lateral position.
Correct Answer: D
Explanation: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intervention to improve oxygenation. The first and most effective step is to
reposition the client to her side to remove pressure from the inferior vena cava and
improve blood flow. Other interventions like oxygen and IV fluids should follow once the
position is changed.
3. The nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. Which
findings would indicate magnesium toxicity? (Select all that apply)
A. Absent deep tendon reflexes
B. Respiratory rate of 10 breaths/min
C. Urinary output of 50 mL/hr
D. Decreased level of consciousness
E. Fetal tachycardia
,Correct Answer: A,B,D
Explanation: Magnesium sulfate is a central nervous system depressant, and toxicity can
lead to life-threatening complications. Classic signs of toxicity include the loss of deep
tendon reflexes, respiratory depression (less than 12 breaths/min), and altered mental
status or lethargy. While low urinary output can lead to toxicity, 50 mL/hr is considered
adequate; however, anything less than 30 mL/hr would be concerning for magnesium
accumulation.
4. During a vaginal examination, the nurse notes that the umbilical cord is protruding from
the vagina. What is the immediate priority action?
A. Place the client in a Trendelenburg or knee-chest position.
B. Apply a warm, saline-soaked gauze to the cord.
C. Attempt to push the cord back into the uterus.
D. Call the healthcare provider to schedule a vacuum extraction.
Correct Answer: A
Explanation: A prolapsed umbilical cord is a medical emergency because the presenting
part can compress the cord, cutting off fetal oxygen. Placing the mother in a Trendelenburg
or knee-chest position uses gravity to shift the fetus off the cord. The nurse should also
maintain manual upward pressure on the presenting part until a cesarean section can be
performed.
, 5. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Placenta previa
B. Placental abruption
C. Preterm labor
D. Ruptured uterus
Correct Answer: A
Explanation: Painless, bright red vaginal bleeding in the second or third trimester is a
hallmark sign of placenta previa, where the placenta covers the cervical os. In contrast,
placental abruption typically presents with painful, dark red bleeding and uterine rigidity.
It is critical to avoid vaginal exams in these clients until the placental location is confirmed
by ultrasound.
6. A nurse is monitoring a client in labor who is dilated to 9 cm and expresses a strong urge to
push. The nurse should recognize this as which phase of labor?
A. Transition phase
B. Active phase
C. Latent phase
D. Second stage
Correct Answer: A
