NUR 231 Exam 2 Actual Exam V3 | NUR 231 Childbearing & Child
Caring Family (NUR231 Exam 2) | Galen College of Nursing
1. A client in active labor has an electronic fetal monitor (EFM) showing late decelerations.
What should be the nurse’s first action?
A. Document the findings as a normal physiological response.
B. Increase the IV rate of maintenance fluids.
C. Administer oxygen via a non-rebreather mask at 8-10 L/min.
D. Reposition the client to the side-lying position.
Answer: D
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intervention to improve fetal oxygenation. Repositioning the client to a side-
lying position is the initial priority to remove pressure from the vena cava and improve
blood flow. Following repositioning, the nurse should then consider fluid boluses, oxygen,
and notifying the provider.
2. A nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding requires immediate notification of the provider?
A. A feeling of warmth and flushing.
B. Urine output of 40 mL per hour.
C. Respiratory rate of 14 breaths per minute.
D. Absent deep tendon reflexes.
Answer: D
Rationale: Absent deep tendon reflexes (DTRs) are a sign of Magnesium Sulfate toxicity
and signify potential central nervous system depression. While flushing is a common side
effect and a respiratory rate of 14 is acceptable, the loss of DTRs precedes respiratory
collapse. The nurse must immediately stop the infusion and notify the provider while
preparing Calcium Gluconate.
3. During the transition phase of the first stage of labor, a client becomes irritable and
expresses that she ‘cannot do this anymore.’ Which nursing intervention is most appropriate?
A. Encourage the client to take a nap between contractions.
B. Provide short, clear instructions and firm support.
C. Administer an IV opioid analgesic for pain relief.
D. Instruct the partner to leave the room to reduce stimulation.
,Answer: B
Rationale: The transition phase (8-10 cm) is characterized by intense contractions,
irritability, and a loss of control. Clients in this stage require direct, concise communication
and a constant supportive presence to help them focus. Pain medication is usually avoided
at this stage to prevent respiratory depression in the newborn.
4. A nurse performs Leopold maneuvers on a pregnant client and feels a soft, round mass in
the fundus and a hard, smooth surface on the client’s left side. What is the fetal position?
A. Right Occiput Anterior (ROA)
B. Transverse lie
C. Breech presentation
D. Left Occiput Anterior (LOA)
Answer: D
Rationale: Leopold maneuvers identify fetal part, presentation, and lie. Feeling the ‘soft,
round mass’ (buttocks) in the fundus suggests a cephalic presentation, while the ‘hard,
smooth surface’ (back) on the mother’s left indicates the back is oriented toward the left.
This finding is consistent with an LOA or Left Occiput position.
5. A client at 34 weeks gestation presents with sudden, dark red vaginal bleeding and a
board-like, tender abdomen. What complication does the nurse suspect?
A. Placenta Previa
B. Uterine rupture
C. Abruptio Placentae
D. Spontaneous abortion
Answer: C
Rationale: Abruptio placentae is the premature separation of the placenta and is
characterized by painful, dark red bleeding and uterine rigidity. In contrast, placenta previa
typically involves painless, bright red bleeding. This condition is a medical emergency due
to the risk of maternal hemorrhage and fetal distress.
6. Immediately after an epidural block is administered, the client’s blood pressure drops from
120/80 to 90/50 mmHg. What is the priority nursing intervention?
A. Place the client in a Trendelenburg position.
B. Call for an emergency Cesarean section.
C. Administer IV Epinephrine immediately.
D. Increase the IV fluid rate and turn the client to the side.
, Answer: D
Rationale: Maternal hypotension is a common side effect of epidural anesthesia due to
sympathetic block. The nurse should immediately increase the infusion of non-dextrose IV
fluids and reposition the client to her side to improve cardiac output. These steps help
restore placental perfusion and stabilize the mother’s blood pressure.
7. Which finding on a fetal monitor strip would indicate a Category III fetal heart rate
pattern?
A. Early decelerations with moderate variability.
B. Absent variability with recurrent late decelerations.
C. Variable decelerations with a rapid return to baseline.
D. Accelerations of 15 bpm lasting 15 seconds.
Answer: B
Rationale: Category III FHR patterns are abnormal and predictive of abnormal fetal acid-
base status. Features include absent baseline FHR variability accompanied by recurrent
late decelerations, recurrent variable decelerations, or bradycardia. This situation requires
prompt evaluation and potential delivery.
8. A nurse is monitoring a client during an Oxytocin (Pitocin) induction. Which uterine
contraction pattern necessitates stopping the infusion?
A. Contractions every 3 to 5 minutes lasting 60 seconds.
B. A cervical change of 1 cm per hour.
C. Uterine resting tone of 15 mmHg between contractions.
D. Contractions occurring every 90 seconds and lasting 100 seconds.
Answer: D
Rationale: Uterine tachysystole occurs when contractions happen more frequently than
every 2 minutes or last longer than 90 seconds. This prevents adequate uterine resting
time and compromises fetal oxygenation. The nurse must stop the Oxytocin infusion to
allow the uterus to rest and ensure fetal safety.
9. A client who is Rh-negative gives birth to an Rh-positive newborn. When should the nurse
administer the Rho(D) immune globulin (RhoGAM)?
A. 24 hours before the planned discharge.
B. Immediately upon the onset of labor.
C. Only if the Indirect Coombs test is positive.
D. Within 72 hours after delivery.
Caring Family (NUR231 Exam 2) | Galen College of Nursing
1. A client in active labor has an electronic fetal monitor (EFM) showing late decelerations.
What should be the nurse’s first action?
A. Document the findings as a normal physiological response.
B. Increase the IV rate of maintenance fluids.
C. Administer oxygen via a non-rebreather mask at 8-10 L/min.
D. Reposition the client to the side-lying position.
Answer: D
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intervention to improve fetal oxygenation. Repositioning the client to a side-
lying position is the initial priority to remove pressure from the vena cava and improve
blood flow. Following repositioning, the nurse should then consider fluid boluses, oxygen,
and notifying the provider.
2. A nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding requires immediate notification of the provider?
A. A feeling of warmth and flushing.
B. Urine output of 40 mL per hour.
C. Respiratory rate of 14 breaths per minute.
D. Absent deep tendon reflexes.
Answer: D
Rationale: Absent deep tendon reflexes (DTRs) are a sign of Magnesium Sulfate toxicity
and signify potential central nervous system depression. While flushing is a common side
effect and a respiratory rate of 14 is acceptable, the loss of DTRs precedes respiratory
collapse. The nurse must immediately stop the infusion and notify the provider while
preparing Calcium Gluconate.
3. During the transition phase of the first stage of labor, a client becomes irritable and
expresses that she ‘cannot do this anymore.’ Which nursing intervention is most appropriate?
A. Encourage the client to take a nap between contractions.
B. Provide short, clear instructions and firm support.
C. Administer an IV opioid analgesic for pain relief.
D. Instruct the partner to leave the room to reduce stimulation.
,Answer: B
Rationale: The transition phase (8-10 cm) is characterized by intense contractions,
irritability, and a loss of control. Clients in this stage require direct, concise communication
and a constant supportive presence to help them focus. Pain medication is usually avoided
at this stage to prevent respiratory depression in the newborn.
4. A nurse performs Leopold maneuvers on a pregnant client and feels a soft, round mass in
the fundus and a hard, smooth surface on the client’s left side. What is the fetal position?
A. Right Occiput Anterior (ROA)
B. Transverse lie
C. Breech presentation
D. Left Occiput Anterior (LOA)
Answer: D
Rationale: Leopold maneuvers identify fetal part, presentation, and lie. Feeling the ‘soft,
round mass’ (buttocks) in the fundus suggests a cephalic presentation, while the ‘hard,
smooth surface’ (back) on the mother’s left indicates the back is oriented toward the left.
This finding is consistent with an LOA or Left Occiput position.
5. A client at 34 weeks gestation presents with sudden, dark red vaginal bleeding and a
board-like, tender abdomen. What complication does the nurse suspect?
A. Placenta Previa
B. Uterine rupture
C. Abruptio Placentae
D. Spontaneous abortion
Answer: C
Rationale: Abruptio placentae is the premature separation of the placenta and is
characterized by painful, dark red bleeding and uterine rigidity. In contrast, placenta previa
typically involves painless, bright red bleeding. This condition is a medical emergency due
to the risk of maternal hemorrhage and fetal distress.
6. Immediately after an epidural block is administered, the client’s blood pressure drops from
120/80 to 90/50 mmHg. What is the priority nursing intervention?
A. Place the client in a Trendelenburg position.
B. Call for an emergency Cesarean section.
C. Administer IV Epinephrine immediately.
D. Increase the IV fluid rate and turn the client to the side.
, Answer: D
Rationale: Maternal hypotension is a common side effect of epidural anesthesia due to
sympathetic block. The nurse should immediately increase the infusion of non-dextrose IV
fluids and reposition the client to her side to improve cardiac output. These steps help
restore placental perfusion and stabilize the mother’s blood pressure.
7. Which finding on a fetal monitor strip would indicate a Category III fetal heart rate
pattern?
A. Early decelerations with moderate variability.
B. Absent variability with recurrent late decelerations.
C. Variable decelerations with a rapid return to baseline.
D. Accelerations of 15 bpm lasting 15 seconds.
Answer: B
Rationale: Category III FHR patterns are abnormal and predictive of abnormal fetal acid-
base status. Features include absent baseline FHR variability accompanied by recurrent
late decelerations, recurrent variable decelerations, or bradycardia. This situation requires
prompt evaluation and potential delivery.
8. A nurse is monitoring a client during an Oxytocin (Pitocin) induction. Which uterine
contraction pattern necessitates stopping the infusion?
A. Contractions every 3 to 5 minutes lasting 60 seconds.
B. A cervical change of 1 cm per hour.
C. Uterine resting tone of 15 mmHg between contractions.
D. Contractions occurring every 90 seconds and lasting 100 seconds.
Answer: D
Rationale: Uterine tachysystole occurs when contractions happen more frequently than
every 2 minutes or last longer than 90 seconds. This prevents adequate uterine resting
time and compromises fetal oxygenation. The nurse must stop the Oxytocin infusion to
allow the uterus to rest and ensure fetal safety.
9. A client who is Rh-negative gives birth to an Rh-positive newborn. When should the nurse
administer the Rho(D) immune globulin (RhoGAM)?
A. 24 hours before the planned discharge.
B. Immediately upon the onset of labor.
C. Only if the Indirect Coombs test is positive.
D. Within 72 hours after delivery.
