NSG 432 Exam 2 V2 | 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 client in the labor and delivery unit. Which of the following findings
would indicate that the client is experiencing true labor? (Select all that apply)
A. Contractions are regular and become stronger and closer together over time.
B. Pain is primarily felt in the upper abdomen and is relieved by walking.
C. Cervical change such as dilation and effacement is occurring.
D. The bloody show is present.
E. Contractions continue despite resting or changing positions.
F. Contractions are irregular and stop when the client drinks water.
Correct Answer: A, C, D, E
Explanation: True labor is characterized by cervical effacement and dilation, which is the
most definitive sign. The contractions in true labor typically become more regular and
intense, and they are not relieved by activity or hydration. In contrast, false labor often
involves irregular contractions that subside with rest or walking.
,2. A client at 38 weeks gestation receives an epidural for pain management during labor.
Which nursing intervention is the priority immediately following the procedure?
A. Perform a sterile vaginal exam to check progress.
B. Monitor the client’s blood pressure every 2 to 5 minutes.
C. Assess the client’s ability to move their lower extremities.
D. Encourage the client to ambulate to promote fetal descent.
Correct Answer: B
Explanation: Maternal hypotension is a common side effect of epidural anesthesia due to
sympathetic blockade. The nurse must monitor blood pressure closely to detect drops that
could impair uteroplacental perfusion. Immediate interventions such as IV fluid boluses
and repositioning are necessary if hypotension occurs.
3. The fetal heart rate monitor shows a pattern of early decelerations. What is the nurse’s
best action?
A. Prepare for an emergency cesarean section.
B. Administer oxygen at 10L/min via non-rebreather mask.
C. Continue to monitor the client, as this is a benign finding.
D. Turn the client to the left lateral position.
Correct Answer: C
, Explanation: Early decelerations are caused by fetal head compression during
contractions and are considered a normal, reassuring finding. They typically mirror the
contraction, starting and ending at the same time. No medical intervention is required
other than continued routine monitoring.
4. A nurse is caring for a client who is receiving Magnesium Sulfate for preeclampsia. Which
of the following assessment findings indicates toxicity? (Select all that apply)
A. Absence of deep tendon reflexes (DTRs).
B. Respiratory rate of 10 breaths per minute.
C. Urinary output of 50 mL per hour.
D. Serum magnesium level of 9 mg/dL.
E. Decreased level of consciousness.
Correct Answer: A, B, D, E
Explanation: Magnesium sulfate toxicity is a life-threatening condition that presents with
respiratory depression and loss of reflexes. A therapeutic level is generally 4-7 mg/dL, so 9
mg/dL is considered toxic. The nurse must be prepared to stop the infusion and administer
calcium gluconate if these signs appear.
5. Following an amniotomy (AROM), the nurse notes a sudden drop in the fetal heart rate
with deep, variable decelerations. What is the priority nursing action?
A. Perform a vaginal exam to check for a prolapsed cord.
B. Increase the rate of the oxytocin infusion.
Care of the Childbearing Family | Actual
Q&A with Rationale (NSG432 Exam 2) |
Grand Canyon University
1. A nurse is assessing a client in the labor and delivery unit. Which of the following findings
would indicate that the client is experiencing true labor? (Select all that apply)
A. Contractions are regular and become stronger and closer together over time.
B. Pain is primarily felt in the upper abdomen and is relieved by walking.
C. Cervical change such as dilation and effacement is occurring.
D. The bloody show is present.
E. Contractions continue despite resting or changing positions.
F. Contractions are irregular and stop when the client drinks water.
Correct Answer: A, C, D, E
Explanation: True labor is characterized by cervical effacement and dilation, which is the
most definitive sign. The contractions in true labor typically become more regular and
intense, and they are not relieved by activity or hydration. In contrast, false labor often
involves irregular contractions that subside with rest or walking.
,2. A client at 38 weeks gestation receives an epidural for pain management during labor.
Which nursing intervention is the priority immediately following the procedure?
A. Perform a sterile vaginal exam to check progress.
B. Monitor the client’s blood pressure every 2 to 5 minutes.
C. Assess the client’s ability to move their lower extremities.
D. Encourage the client to ambulate to promote fetal descent.
Correct Answer: B
Explanation: Maternal hypotension is a common side effect of epidural anesthesia due to
sympathetic blockade. The nurse must monitor blood pressure closely to detect drops that
could impair uteroplacental perfusion. Immediate interventions such as IV fluid boluses
and repositioning are necessary if hypotension occurs.
3. The fetal heart rate monitor shows a pattern of early decelerations. What is the nurse’s
best action?
A. Prepare for an emergency cesarean section.
B. Administer oxygen at 10L/min via non-rebreather mask.
C. Continue to monitor the client, as this is a benign finding.
D. Turn the client to the left lateral position.
Correct Answer: C
, Explanation: Early decelerations are caused by fetal head compression during
contractions and are considered a normal, reassuring finding. They typically mirror the
contraction, starting and ending at the same time. No medical intervention is required
other than continued routine monitoring.
4. A nurse is caring for a client who is receiving Magnesium Sulfate for preeclampsia. Which
of the following assessment findings indicates toxicity? (Select all that apply)
A. Absence of deep tendon reflexes (DTRs).
B. Respiratory rate of 10 breaths per minute.
C. Urinary output of 50 mL per hour.
D. Serum magnesium level of 9 mg/dL.
E. Decreased level of consciousness.
Correct Answer: A, B, D, E
Explanation: Magnesium sulfate toxicity is a life-threatening condition that presents with
respiratory depression and loss of reflexes. A therapeutic level is generally 4-7 mg/dL, so 9
mg/dL is considered toxic. The nurse must be prepared to stop the infusion and administer
calcium gluconate if these signs appear.
5. Following an amniotomy (AROM), the nurse notes a sudden drop in the fetal heart rate
with deep, variable decelerations. What is the priority nursing action?
A. Perform a vaginal exam to check for a prolapsed cord.
B. Increase the rate of the oxytocin infusion.
