NUR 2804C: Module 2 Giddens Exam with
verified answers and rationale
graded A+ new!!
Question 1
A nurse is conducting a prenatal education class on fetal development. Which statement by a
participant indicates a correct understanding of the embryonic stage?
A. "The embryonic stage lasts from fertilization until the end of the second week."
B. "During the embryonic stage, the fetus is least vulnerable to teratogens."
C. "This stage lasts from week 3 to week 8, during which organ systems are established."
D. "The baby's sex is determined during the embryonic stage."
Answer: C
Rationale: The embryonic stage begins at week 3 (day 15) and lasts until the end of week 8. This is
the period of rapid organogenesis, making the embryo highly vulnerable to environmental
teratogens. Determination of genetic sex occurs at fertilization (pre-embryonic stage).
Question 2
A woman at 36 weeks of gestation lies flat on her back during an ultrasound examination. She
complains of feeling dizzy, lightheaded, and clammy. What is the nurse's priority action?
A. Administer oxygen via non-rebreather mask at 10 L/min.
B. Assist the patient to turn onto her left side.
C. Increase the rate of the intravenous infusion.
D. Place the patient in a Trendelenburg position.
Answer: B
Rationale: The patient is experiencing supine hypotensive syndrome (vena cava syndrome) caused
by the heavy uterus compressing the inferior vena cava, reducing venous return to the heart.
Turning the patient onto her side (preferably left) relieves the pressure and restores cardiac output
and blood pressure.
Question 3
A nurse is reviewing the lab results of a pregnant patient at her initial prenatal visit at 8 weeks of
gestation. The patient's blood type is O-negative. Which clinical intervention is indicated?
,A. Administer Rho(D) immune globulin (RhoGAM) immediately.
B. Schedule Rho(D) immune globulin administration at 28 weeks of gestation.
C. Administer Rho(D) immune globulin within 72 hours after delivery only.
D. No action is required unless the father is also Rh-negative.
Answer: B
Rationale: For Rh-negative unsensitized patients, Rho(D) immune globulin is routinely administered
prophylactically at 28 weeks of gestation, and again within 72 hours after delivery if the newborn is
Rh-positive.
Question 4
During a prenatal visit, a patient at 20 weeks of gestation asks why her provider measures the fundal
height. How should the nurse explain the purpose of this measurement?
A. "It estimates the exact weight of your baby."
B. "It helps determine if the baby is in a breech position."
C. "The measurement in centimeters should approximately equal the weeks of gestation."
D. "It measures the amount of amniotic fluid present."
Answer: C
Rationale: From 18 to 32 weeks of gestation, the fundal height in centimeters is approximately equal
to the gestational age in weeks (plus or minus 2 cm), assuming a single fetus and empty bladder.
Question 5
A nurse is teaching a pregnant client about warning signs that must be reported immediately. Which
symptom should the client report to the healthcare provider?
A. Leukorrhea (increased thin, white vaginal discharge)
B. Urinary frequency in the first trimester
C. Facial swelling and severe, persistent headache
D. Lower backache relieved by rest
Answer: C
Rationale: Facial swelling (edema of the hands/face) and a severe, persistent headache are warning
signs of preeclampsia and must be evaluated immediately. Leukorrhea, urinary frequency, and mild
backache are common, expected discomforts of pregnancy.
Question 6
,A client presents to the clinic stating her last menstrual period (LMP) began on October 10, 2023.
Using Naegele’s rule, what is her estimated date of delivery (EDD)?
A. July 17, 2024
B. July 3, 2024
C. August 17, 2024
D. June 17, 2024
Answer: A
Rationale: Naegele’s rule is calculated by subtracting 3 months from the first day of the LMP, adding
7 days, and adjusting the year. October 10 minus 3 months = July; add 7 days = July 17 of the
following year (2024).
Question 7
Which of the following is considered a positive sign of pregnancy?
A. A positive serum pregnancy test (hCG)
B. Fetal heart tones detected by Doppler
C. Chadwick's sign (bluish discoloration of the cervix)
D. Braxton Hicks contractions
Answer: B
Rationale: Positive signs of pregnancy are attributed only to the presence of a fetus (e.g., hearing
fetal heart tones, ultrasound visualization, or fetal movement felt by an examiner). hCG levels (A)
and Chadwick's sign (C) are probable signs, while Braxton Hicks (D) is also a probable sign.
Question 8
A pregnant client at 32 weeks of gestation is diagnosed with gestational diabetes. The nurse
understands that this condition is primarily caused by which hormone?
A. Progesterone
B. Human placental lactogen (hPL)
C. Estrogen
D. Human chorionic gonadotropin (hCG)
Answer: B
Rationale: Human placental lactogen (hPL) is an antagonist to insulin, produced by the placenta. It
increases maternal insulin resistance to ensure adequate glucose is available for the growing fetus.
, Question 9
A nurse is assessing a postpartum client 4 hours after a vaginal delivery. The nurse notes that the
fundus is firm, 2 fingerbreadths above the umbilicus, and deviated to the right. What is the nurse's
immediate action?
A. Massage the fundus vigorously.
B. Notify the primary care provider.
C. Assist the client to the bathroom to void.
D. Administer an intramuscular injection of oxytocin.
Answer: C
Rationale: A fundus that is elevated and deviated to the right is highly indicative of a distended
bladder. A full bladder displaces the uterus, preventing it from contracting efficiently, which
increases the risk of hemorrhage. Massaging is not required if the fundus is already firm.
Question 10
A client in labor is dilated to 5 cm and requests an epidural. What is the priority nursing
assessment/intervention prior to the initiation of epidural anesthesia?
A. Assess the client’s deep tendon reflexes.
B. Administer a 500 to 1,000 mL bolus of IV lactated Ringer’s solution.
C. Determine the client's cervical effacement.
D. Administer an oral antacid.
Answer: B
Rationale: Epidural anesthesia can cause significant maternal hypotension due to sympathetic
blockade. An IV fluid bolus is administered prior to the block to expand intravascular volume and
minimize the risk of hypotension.
Question 11
The nurse is monitoring a client in active labor and notes a pattern of late decelerations on the fetal
heart rate (FHR) monitor. What does this pattern indicate?
A. Head compression
B. Cord compression
C. Uteroplacental insufficiency
D. Fetal movement
Answer: C
verified answers and rationale
graded A+ new!!
Question 1
A nurse is conducting a prenatal education class on fetal development. Which statement by a
participant indicates a correct understanding of the embryonic stage?
A. "The embryonic stage lasts from fertilization until the end of the second week."
B. "During the embryonic stage, the fetus is least vulnerable to teratogens."
C. "This stage lasts from week 3 to week 8, during which organ systems are established."
D. "The baby's sex is determined during the embryonic stage."
Answer: C
Rationale: The embryonic stage begins at week 3 (day 15) and lasts until the end of week 8. This is
the period of rapid organogenesis, making the embryo highly vulnerable to environmental
teratogens. Determination of genetic sex occurs at fertilization (pre-embryonic stage).
Question 2
A woman at 36 weeks of gestation lies flat on her back during an ultrasound examination. She
complains of feeling dizzy, lightheaded, and clammy. What is the nurse's priority action?
A. Administer oxygen via non-rebreather mask at 10 L/min.
B. Assist the patient to turn onto her left side.
C. Increase the rate of the intravenous infusion.
D. Place the patient in a Trendelenburg position.
Answer: B
Rationale: The patient is experiencing supine hypotensive syndrome (vena cava syndrome) caused
by the heavy uterus compressing the inferior vena cava, reducing venous return to the heart.
Turning the patient onto her side (preferably left) relieves the pressure and restores cardiac output
and blood pressure.
Question 3
A nurse is reviewing the lab results of a pregnant patient at her initial prenatal visit at 8 weeks of
gestation. The patient's blood type is O-negative. Which clinical intervention is indicated?
,A. Administer Rho(D) immune globulin (RhoGAM) immediately.
B. Schedule Rho(D) immune globulin administration at 28 weeks of gestation.
C. Administer Rho(D) immune globulin within 72 hours after delivery only.
D. No action is required unless the father is also Rh-negative.
Answer: B
Rationale: For Rh-negative unsensitized patients, Rho(D) immune globulin is routinely administered
prophylactically at 28 weeks of gestation, and again within 72 hours after delivery if the newborn is
Rh-positive.
Question 4
During a prenatal visit, a patient at 20 weeks of gestation asks why her provider measures the fundal
height. How should the nurse explain the purpose of this measurement?
A. "It estimates the exact weight of your baby."
B. "It helps determine if the baby is in a breech position."
C. "The measurement in centimeters should approximately equal the weeks of gestation."
D. "It measures the amount of amniotic fluid present."
Answer: C
Rationale: From 18 to 32 weeks of gestation, the fundal height in centimeters is approximately equal
to the gestational age in weeks (plus or minus 2 cm), assuming a single fetus and empty bladder.
Question 5
A nurse is teaching a pregnant client about warning signs that must be reported immediately. Which
symptom should the client report to the healthcare provider?
A. Leukorrhea (increased thin, white vaginal discharge)
B. Urinary frequency in the first trimester
C. Facial swelling and severe, persistent headache
D. Lower backache relieved by rest
Answer: C
Rationale: Facial swelling (edema of the hands/face) and a severe, persistent headache are warning
signs of preeclampsia and must be evaluated immediately. Leukorrhea, urinary frequency, and mild
backache are common, expected discomforts of pregnancy.
Question 6
,A client presents to the clinic stating her last menstrual period (LMP) began on October 10, 2023.
Using Naegele’s rule, what is her estimated date of delivery (EDD)?
A. July 17, 2024
B. July 3, 2024
C. August 17, 2024
D. June 17, 2024
Answer: A
Rationale: Naegele’s rule is calculated by subtracting 3 months from the first day of the LMP, adding
7 days, and adjusting the year. October 10 minus 3 months = July; add 7 days = July 17 of the
following year (2024).
Question 7
Which of the following is considered a positive sign of pregnancy?
A. A positive serum pregnancy test (hCG)
B. Fetal heart tones detected by Doppler
C. Chadwick's sign (bluish discoloration of the cervix)
D. Braxton Hicks contractions
Answer: B
Rationale: Positive signs of pregnancy are attributed only to the presence of a fetus (e.g., hearing
fetal heart tones, ultrasound visualization, or fetal movement felt by an examiner). hCG levels (A)
and Chadwick's sign (C) are probable signs, while Braxton Hicks (D) is also a probable sign.
Question 8
A pregnant client at 32 weeks of gestation is diagnosed with gestational diabetes. The nurse
understands that this condition is primarily caused by which hormone?
A. Progesterone
B. Human placental lactogen (hPL)
C. Estrogen
D. Human chorionic gonadotropin (hCG)
Answer: B
Rationale: Human placental lactogen (hPL) is an antagonist to insulin, produced by the placenta. It
increases maternal insulin resistance to ensure adequate glucose is available for the growing fetus.
, Question 9
A nurse is assessing a postpartum client 4 hours after a vaginal delivery. The nurse notes that the
fundus is firm, 2 fingerbreadths above the umbilicus, and deviated to the right. What is the nurse's
immediate action?
A. Massage the fundus vigorously.
B. Notify the primary care provider.
C. Assist the client to the bathroom to void.
D. Administer an intramuscular injection of oxytocin.
Answer: C
Rationale: A fundus that is elevated and deviated to the right is highly indicative of a distended
bladder. A full bladder displaces the uterus, preventing it from contracting efficiently, which
increases the risk of hemorrhage. Massaging is not required if the fundus is already firm.
Question 10
A client in labor is dilated to 5 cm and requests an epidural. What is the priority nursing
assessment/intervention prior to the initiation of epidural anesthesia?
A. Assess the client’s deep tendon reflexes.
B. Administer a 500 to 1,000 mL bolus of IV lactated Ringer’s solution.
C. Determine the client's cervical effacement.
D. Administer an oral antacid.
Answer: B
Rationale: Epidural anesthesia can cause significant maternal hypotension due to sympathetic
blockade. An IV fluid bolus is administered prior to the block to expand intravascular volume and
minimize the risk of hypotension.
Question 11
The nurse is monitoring a client in active labor and notes a pattern of late decelerations on the fetal
heart rate (FHR) monitor. What does this pattern indicate?
A. Head compression
B. Cord compression
C. Uteroplacental insufficiency
D. Fetal movement
Answer: C
