NSG 432 Exam 3 V2 | NSG 432 Nursing
Care of the Childbearing Family | Actual
Q&A with Rationale (NSG432 Exam 3) |
Grand Canyon University
1. A nurse is assessing a client at 34 weeks gestation who is suspected of having
preeclampsia. Which of the following assessment findings should the nurse identify as
indicators of this condition? (Select all that apply)
A. Blood pressure of 148/92 mmHg
B. Proteinuria of 3+ on dipstick
C. Generalized edema, especially in the face and hands
D. Epigastric pain
E. Increased urine output
F. Visual disturbances such as blurred vision
Correct Answer: A, B, C, D, F
Explanation: Preeclampsia is characterized by hypertension and proteinuria occurring
after 20 weeks of gestation. Epigastric pain and visual disturbances are considered severe
features indicating potential hepatic involvement or central nervous system irritability.
Increased urine output is not a sign; rather, oliguria is often observed in worsening cases
due to decreased renal perfusion.
,2. A client is receiving Magnesium Sulfate for the management of preeclampsia. The nurse
should monitor for which sign of magnesium toxicity?
A. Hyperreflexia
B. Tachycardia
C. Increased urinary output
D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Explanation: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclamptic patients. A respiratory rate below 12 breaths per minute is a
critical indicator of magnesium toxicity and requires immediate intervention. Other signs
include absent deep tendon reflexes and decreased urinary output, not hyperreflexia or
tachycardia.
3. A laboring client’s fetal heart rate (FHR) monitor shows late decelerations. Which action
should the nurse take first?
A. Increase the Oxytocin (Pitocin) infusion rate
B. Prepare the client for an immediate cesarean section
C. Assist the client into a left-lateral position
D. Perform a vaginal exam to check for cord prolapse
Correct Answer: C
,Explanation: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intrauterine resuscitation. The first step is to reposition the client to her side to
improve blood flow to the placenta and fetus. Following this, the nurse should increase IV
fluids, administer oxygen, and discontinue any oxytocin infusions.
4. A nurse is caring for a client who is at 30 weeks gestation and in preterm labor. Which
medication should the nurse anticipate administering to promote fetal lung maturity?
A. Betamethasone
B. Indomethacin
C. Terbutaline
D. Magnesium Sulfate
Correct Answer: A
Explanation: Betamethasone is a corticosteroid administered to the mother to stimulate
surfactant production in the preterm fetus. This intervention helps reduce the risk of
respiratory distress syndrome (RDS) and intraventricular hemorrhage. It is typically given
in two doses 24 hours apart when delivery is anticipated within 7 days.
5. Which factors increase a client’s risk for developing postpartum hemorrhage (PPH)? (Select
all that apply)
A. Overdistended uterus (e.g., polyhydramnios, multiples)
B. Prolonged labor or rapid labor
C. Magnesium sulfate administration during labor
, D. Retained placental fragments
E. Nulliparity with a standard length labor
F. Chorioamnionitis
Correct Answer: A, B, C, D, F
Explanation: Postpartum hemorrhage is most commonly caused by uterine atony, which
can result from overdistention, fatigue from long labor, or medications that relax the uterus
like magnesium sulfate. Retained fragments prevent the uterus from contracting down
effectively, leading to continued bleeding. Infection like chorioamnionitis also weakens the
uterine muscle’s ability to contract effectively after birth.
6. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Abruptio placentae
B. Ruptured uterus
C. Preterm labor
D. Placenta previa
Correct Answer: D
Explanation: Placenta previa is classically characterized by the onset of painless, bright
red vaginal bleeding during the second or third trimester. This occurs because the placenta
Care of the Childbearing Family | Actual
Q&A with Rationale (NSG432 Exam 3) |
Grand Canyon University
1. A nurse is assessing a client at 34 weeks gestation who is suspected of having
preeclampsia. Which of the following assessment findings should the nurse identify as
indicators of this condition? (Select all that apply)
A. Blood pressure of 148/92 mmHg
B. Proteinuria of 3+ on dipstick
C. Generalized edema, especially in the face and hands
D. Epigastric pain
E. Increased urine output
F. Visual disturbances such as blurred vision
Correct Answer: A, B, C, D, F
Explanation: Preeclampsia is characterized by hypertension and proteinuria occurring
after 20 weeks of gestation. Epigastric pain and visual disturbances are considered severe
features indicating potential hepatic involvement or central nervous system irritability.
Increased urine output is not a sign; rather, oliguria is often observed in worsening cases
due to decreased renal perfusion.
,2. A client is receiving Magnesium Sulfate for the management of preeclampsia. The nurse
should monitor for which sign of magnesium toxicity?
A. Hyperreflexia
B. Tachycardia
C. Increased urinary output
D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Explanation: Magnesium sulfate is a central nervous system depressant used to prevent
seizures in preeclamptic patients. A respiratory rate below 12 breaths per minute is a
critical indicator of magnesium toxicity and requires immediate intervention. Other signs
include absent deep tendon reflexes and decreased urinary output, not hyperreflexia or
tachycardia.
3. A laboring client’s fetal heart rate (FHR) monitor shows late decelerations. Which action
should the nurse take first?
A. Increase the Oxytocin (Pitocin) infusion rate
B. Prepare the client for an immediate cesarean section
C. Assist the client into a left-lateral position
D. Perform a vaginal exam to check for cord prolapse
Correct Answer: C
,Explanation: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intrauterine resuscitation. The first step is to reposition the client to her side to
improve blood flow to the placenta and fetus. Following this, the nurse should increase IV
fluids, administer oxygen, and discontinue any oxytocin infusions.
4. A nurse is caring for a client who is at 30 weeks gestation and in preterm labor. Which
medication should the nurse anticipate administering to promote fetal lung maturity?
A. Betamethasone
B. Indomethacin
C. Terbutaline
D. Magnesium Sulfate
Correct Answer: A
Explanation: Betamethasone is a corticosteroid administered to the mother to stimulate
surfactant production in the preterm fetus. This intervention helps reduce the risk of
respiratory distress syndrome (RDS) and intraventricular hemorrhage. It is typically given
in two doses 24 hours apart when delivery is anticipated within 7 days.
5. Which factors increase a client’s risk for developing postpartum hemorrhage (PPH)? (Select
all that apply)
A. Overdistended uterus (e.g., polyhydramnios, multiples)
B. Prolonged labor or rapid labor
C. Magnesium sulfate administration during labor
, D. Retained placental fragments
E. Nulliparity with a standard length labor
F. Chorioamnionitis
Correct Answer: A, B, C, D, F
Explanation: Postpartum hemorrhage is most commonly caused by uterine atony, which
can result from overdistention, fatigue from long labor, or medications that relax the uterus
like magnesium sulfate. Retained fragments prevent the uterus from contracting down
effectively, leading to continued bleeding. Infection like chorioamnionitis also weakens the
uterine muscle’s ability to contract effectively after birth.
6. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Abruptio placentae
B. Ruptured uterus
C. Preterm labor
D. Placenta previa
Correct Answer: D
Explanation: Placenta previa is classically characterized by the onset of painless, bright
red vaginal bleeding during the second or third trimester. This occurs because the placenta
