NSG 432 Exam 2 V3 | NSG 432 Nursing
Care of the Childbearing Family | Actual
Q&A with Rationale (NSG432 Exam 2) |
Grand Canyon University
1. A nurse is caring for a client in the first stage of labor. Which of the following nursing
interventions are appropriate during this stage? Select all that apply.
A. Encouraging frequent position changes to enhance fetal descent.
B. Assessing the fetal heart rate pattern every 15 to 30 minutes depending on risk.
C. Performing a sterile vaginal exam every hour to monitor progress.
D. Assisting the client with breathing techniques and relaxation.
E. Encouraging the client to void every 2 hours to prevent bladder distension.
F. Administering oxytocin at a high-dose starting rate without a pump.
Correct Answer: A, B, D, E
Explanation: During the first stage of labor, position changes help utilize gravity and
maternal movement for fetal rotation. Monitoring fetal heart rate is a standard safety
measure to ensure fetal well-being throughout labor. Maintaining an empty bladder is
crucial as a full bladder can inhibit fetal descent and increase maternal discomfort.
,2. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding should the nurse identify as a priority to report to the provider?
A. Urinary output of 40 mL per hour.
B. Deep tendon reflexes (DTR) of 2+.
C. Reports of feeling warm and flushed.
D. Respiratory rate of 10 breaths per minute.
Correct Answer: D
Explanation: A respiratory rate of 10 breaths per minute indicates potential magnesium
toxicity, which can lead to respiratory arrest. The nurse must prioritize airway and
breathing assessments in clients receiving this high-alert medication. Magnesium sulfate
acts as a central nervous system depressant, making respiratory monitoring vital.
3. A client is at 38 weeks gestation and reports a sudden gush of clear fluid from the vagina.
What is the priority nursing action?
A. Perform a Nitrazine test to confirm the presence of amniotic fluid.
B. Assess the color and odor of the fluid.
C. Assess the fetal heart rate (FHR) for stability.
D. Determine the time of the rupture.
Correct Answer: C
,Explanation: The priority action after the rupture of membranes is to assess the fetal heart
rate to rule out cord prolapse. Fetal well-being is the most critical immediate concern
following a significant change in the intrauterine environment. While documentation and
fluid assessment are important, the physiological status of the fetus takes precedence.
4. A nurse is interpreting a fetal monitor strip and notes a ‘VEAL CHOP’ pattern where the
fetal heart rate decreases after the peak of the contraction and returns to baseline after the
contraction ends. What is the appropriate nursing action?
A. Perform a vaginal exam to check for cord prolapse.
B. Place the client in a side-lying position and administer oxygen.
C. Continue to monitor as these are early decelerations.
D. Increase the rate of the intravenous fluids to increase perfusion.
Correct Answer: B
Explanation: Late decelerations indicate uteroplacental insufficiency, which requires
immediate nursing intervention to improve oxygenation. The nurse should reposition the
mother to the left side to relieve pressure on the vena cava and apply oxygen via a non-
rebreather mask. Notifying the provider and preparing for possible intervention is also
necessary if the pattern persists.
5. Which of the following medications is typically administered to the newborn within the
first two hours of birth to prevent ophthalmia neonatorum?
A. Erythromycin ophthalmic ointment
, B. Vitamin K (Phytonadione)
C. Hepatitis B vaccine
D. Triple Dye
Correct Answer: A
Explanation: Erythromycin ointment is legally mandated in many regions to prevent
neonatal blindness caused by Neisseria gonorrhoeae. The ointment is applied to the lower
conjunctival sac of each eye shortly after birth. This prophylactic measure is standard care
for all newborns regardless of the method of delivery.
6. A nurse is assessing a postpartum client 4 hours after delivery. The fundus is noted to be
boggy and 2 cm above the umbilicus, shifted to the right. What is the nurse’s first action?
A. Assist the client to the bathroom to void.
B. Administer methylergonovine (Methergine) IM.
C. Massage the fundus until firm.
D. Notify the primary care provider immediately.
Correct Answer: A
Explanation: A fundus that is displaced to the right and elevated above the umbilicus is a
classic sign of a distended bladder. A full bladder prevents the uterus from contracting
effectively, which can lead to postpartum hemorrhage. Once the bladder is emptied, the
fundus should return to the midline and firm up with minimal massage.
Care of the Childbearing Family | Actual
Q&A with Rationale (NSG432 Exam 2) |
Grand Canyon University
1. A nurse is caring for a client in the first stage of labor. Which of the following nursing
interventions are appropriate during this stage? Select all that apply.
A. Encouraging frequent position changes to enhance fetal descent.
B. Assessing the fetal heart rate pattern every 15 to 30 minutes depending on risk.
C. Performing a sterile vaginal exam every hour to monitor progress.
D. Assisting the client with breathing techniques and relaxation.
E. Encouraging the client to void every 2 hours to prevent bladder distension.
F. Administering oxytocin at a high-dose starting rate without a pump.
Correct Answer: A, B, D, E
Explanation: During the first stage of labor, position changes help utilize gravity and
maternal movement for fetal rotation. Monitoring fetal heart rate is a standard safety
measure to ensure fetal well-being throughout labor. Maintaining an empty bladder is
crucial as a full bladder can inhibit fetal descent and increase maternal discomfort.
,2. A nurse is monitoring a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding should the nurse identify as a priority to report to the provider?
A. Urinary output of 40 mL per hour.
B. Deep tendon reflexes (DTR) of 2+.
C. Reports of feeling warm and flushed.
D. Respiratory rate of 10 breaths per minute.
Correct Answer: D
Explanation: A respiratory rate of 10 breaths per minute indicates potential magnesium
toxicity, which can lead to respiratory arrest. The nurse must prioritize airway and
breathing assessments in clients receiving this high-alert medication. Magnesium sulfate
acts as a central nervous system depressant, making respiratory monitoring vital.
3. A client is at 38 weeks gestation and reports a sudden gush of clear fluid from the vagina.
What is the priority nursing action?
A. Perform a Nitrazine test to confirm the presence of amniotic fluid.
B. Assess the color and odor of the fluid.
C. Assess the fetal heart rate (FHR) for stability.
D. Determine the time of the rupture.
Correct Answer: C
,Explanation: The priority action after the rupture of membranes is to assess the fetal heart
rate to rule out cord prolapse. Fetal well-being is the most critical immediate concern
following a significant change in the intrauterine environment. While documentation and
fluid assessment are important, the physiological status of the fetus takes precedence.
4. A nurse is interpreting a fetal monitor strip and notes a ‘VEAL CHOP’ pattern where the
fetal heart rate decreases after the peak of the contraction and returns to baseline after the
contraction ends. What is the appropriate nursing action?
A. Perform a vaginal exam to check for cord prolapse.
B. Place the client in a side-lying position and administer oxygen.
C. Continue to monitor as these are early decelerations.
D. Increase the rate of the intravenous fluids to increase perfusion.
Correct Answer: B
Explanation: Late decelerations indicate uteroplacental insufficiency, which requires
immediate nursing intervention to improve oxygenation. The nurse should reposition the
mother to the left side to relieve pressure on the vena cava and apply oxygen via a non-
rebreather mask. Notifying the provider and preparing for possible intervention is also
necessary if the pattern persists.
5. Which of the following medications is typically administered to the newborn within the
first two hours of birth to prevent ophthalmia neonatorum?
A. Erythromycin ophthalmic ointment
, B. Vitamin K (Phytonadione)
C. Hepatitis B vaccine
D. Triple Dye
Correct Answer: A
Explanation: Erythromycin ointment is legally mandated in many regions to prevent
neonatal blindness caused by Neisseria gonorrhoeae. The ointment is applied to the lower
conjunctival sac of each eye shortly after birth. This prophylactic measure is standard care
for all newborns regardless of the method of delivery.
6. A nurse is assessing a postpartum client 4 hours after delivery. The fundus is noted to be
boggy and 2 cm above the umbilicus, shifted to the right. What is the nurse’s first action?
A. Assist the client to the bathroom to void.
B. Administer methylergonovine (Methergine) IM.
C. Massage the fundus until firm.
D. Notify the primary care provider immediately.
Correct Answer: A
Explanation: A fundus that is displaced to the right and elevated above the umbilicus is a
classic sign of a distended bladder. A full bladder prevents the uterus from contracting
effectively, which can lead to postpartum hemorrhage. Once the bladder is emptied, the
fundus should return to the midline and firm up with minimal massage.
