NUR 231 Exam 2 Actual Exam V1 | NUR 231 Childbearing & Child
Caring Family (NUR231 Exam 2) | Galen College of Nursing
1. A nurse is monitoring a client in the active phase of labor. The fetal heart rate (FHR) tracing
shows a pattern of repetitive late decelerations. Which is the priority nursing action?
A. Reposition the client to a lateral position.
B. Increase the rate of the oxytocin infusion.
C. Administer a dose of terbutaline subcutaneously.
D. Perform a sterile vaginal exam to check for cord prolapse.
Answer: A
Rationale: Late decelerations are indicative of uteroplacental insufficiency, which requires
immediate intrauterine resuscitation. Repositioning the client to a side-lying position
improves blood flow to the placenta and is the first step in the protocol. This intervention is
crucial before other measures like oxygen administration or notifying the physician are
initiated.
2. A client at 39 weeks gestation is receiving an oxytocin infusion for labor induction. The
nurse notes contractions every 90 seconds, lasting 70-80 seconds, with a resting tone of 25
mmHg. What is the nurse’s first action?
A. Notify the healthcare provider immediately.
B. Discontinue the oxytocin infusion.
C. Decrease the oxytocin rate by half.
D. Administer oxygen via non-rebreather mask.
Answer: B
Rationale: The client is experiencing tachysystole, which can lead to fetal distress due to
inadequate placental perfusion during uterine rest periods. Discontinuing the oxytocin
infusion is the primary safety intervention to stop overstimulation. The nurse must
prioritize the safety of the fetus by allowing the uterus to relax before resuming any
medication.
3. The nurse is caring for a client who just received an epidural block. Which assessment
finding is most important for the nurse to report to the provider?
A. Maternal heart rate of 105 beats per minute.
B. Maternal blood pressure of 90/58 mmHg.
C. Client report of numbness in the lower extremities.
,D. Fetal heart rate accelerations with movement.
Answer: B
Rationale: Maternal hypotension is a common and dangerous side effect of epidural
anesthesia due to sympathetic nervous system blockade. Low maternal blood pressure
directly reduces placental perfusion, which can lead to fetal hypoxia. The nurse must
monitor blood pressure frequently and intervene with fluid boluses or vasopressors as
ordered.
4. During a vaginal exam, the nurse notes the fetal head is at +2 station. How should the
nurse interpret this finding?
A. The fetal head is 2 cm above the ischial spines.
B. The fetal head is floating above the pelvic inlet.
C. The fetal head is 2 cm below the ischial spines.
D. The fetal head is at the level of the ischial spines.
Answer: C
Rationale: Station is measured in centimeters relative to the ischial spines, where zero
station is the level of the spines. Positive numbers indicate the fetus has descended further
into the birth canal toward the pelvic floor. A station of +2 means the presenting part is 2
cm below the anatomical landmark of the ischial spines.
5. A nurse is caring for a client with preeclampsia receiving magnesium sulfate. Which
assessment finding indicates magnesium toxicity?
A. Hyperactive deep tendon reflexes.
B. Respiratory rate of 10 breaths per minute.
C. Urinary output of 40 mL per hour.
D. Increased maternal blood pressure.
Answer: B
Rationale: Magnesium sulfate is a CNS depressant, and toxicity can manifest as respiratory
depression (less than 12 breaths/min). Other signs include loss of deep tendon reflexes and
decreased urinary output. The nurse must have calcium gluconate readily available as the
antidote for magnesium toxicity.
6. A nurse observes a fetal heart rate pattern that shows a sharp decrease from the baseline
and a sharp return, appearing ‘V’ shaped. What is the likely cause?
A. Fetal head compression.
B. Maternal fever or dehydration.
, C. Umbilical cord compression.
D. Chronic uteroplacental insufficiency.
Answer: C
Rationale: Variable decelerations are characterized by a sudden drop and rapid recovery,
often related to umbilical cord compression. These can occur with or without contractions
and are common after the rupture of membranes. Nursing interventions include maternal
position changes to relieve pressure on the cord.
7. The nurse identifies that a client is in the transition phase of the first stage of labor when
which behavior is observed?
A. The client is talkative and excited about the birth.
B. The client feels an uncontrollable urge to push.
C. The client is experiencing mild contractions every 10 minutes.
D. The client becomes irritable and expresses doubt in her ability to continue.
Answer: D
Rationale: The transition phase (8-10 cm dilation) is characterized by intense contractions
and significant emotional changes, including irritability and loss of control. Clients often
experience nausea, vomiting, and a sense of overwhelm during this final part of the first
stage. Supportive care and encouragement are vital nursing roles during this
physiologically demanding phase.
8. What is the priority nursing intervention immediately following an amniotomy (artificial
rupture of membranes)?
A. Document the color, odor, and amount of amniotic fluid.
B. Check the maternal temperature for signs of infection.
C. Perform pericare and change the underpads.
D. Assess the fetal heart rate for at least one full minute.
Answer: D
Rationale: The greatest risk immediately following the rupture of membranes is umbilical
cord prolapse. The nurse must monitor the fetal heart rate to detect decelerations that
would indicate cord compression. If the FHR is stable, then the nurse can proceed with
assessing fluid characteristics and maternal comfort.
9. A client is diagnosed with a placental abruption. Which clinical finding should the nurse
expect?
A. Sudden onset of severe abdominal pain and a board-like abdomen.
Caring Family (NUR231 Exam 2) | Galen College of Nursing
1. A nurse is monitoring a client in the active phase of labor. The fetal heart rate (FHR) tracing
shows a pattern of repetitive late decelerations. Which is the priority nursing action?
A. Reposition the client to a lateral position.
B. Increase the rate of the oxytocin infusion.
C. Administer a dose of terbutaline subcutaneously.
D. Perform a sterile vaginal exam to check for cord prolapse.
Answer: A
Rationale: Late decelerations are indicative of uteroplacental insufficiency, which requires
immediate intrauterine resuscitation. Repositioning the client to a side-lying position
improves blood flow to the placenta and is the first step in the protocol. This intervention is
crucial before other measures like oxygen administration or notifying the physician are
initiated.
2. A client at 39 weeks gestation is receiving an oxytocin infusion for labor induction. The
nurse notes contractions every 90 seconds, lasting 70-80 seconds, with a resting tone of 25
mmHg. What is the nurse’s first action?
A. Notify the healthcare provider immediately.
B. Discontinue the oxytocin infusion.
C. Decrease the oxytocin rate by half.
D. Administer oxygen via non-rebreather mask.
Answer: B
Rationale: The client is experiencing tachysystole, which can lead to fetal distress due to
inadequate placental perfusion during uterine rest periods. Discontinuing the oxytocin
infusion is the primary safety intervention to stop overstimulation. The nurse must
prioritize the safety of the fetus by allowing the uterus to relax before resuming any
medication.
3. The nurse is caring for a client who just received an epidural block. Which assessment
finding is most important for the nurse to report to the provider?
A. Maternal heart rate of 105 beats per minute.
B. Maternal blood pressure of 90/58 mmHg.
C. Client report of numbness in the lower extremities.
,D. Fetal heart rate accelerations with movement.
Answer: B
Rationale: Maternal hypotension is a common and dangerous side effect of epidural
anesthesia due to sympathetic nervous system blockade. Low maternal blood pressure
directly reduces placental perfusion, which can lead to fetal hypoxia. The nurse must
monitor blood pressure frequently and intervene with fluid boluses or vasopressors as
ordered.
4. During a vaginal exam, the nurse notes the fetal head is at +2 station. How should the
nurse interpret this finding?
A. The fetal head is 2 cm above the ischial spines.
B. The fetal head is floating above the pelvic inlet.
C. The fetal head is 2 cm below the ischial spines.
D. The fetal head is at the level of the ischial spines.
Answer: C
Rationale: Station is measured in centimeters relative to the ischial spines, where zero
station is the level of the spines. Positive numbers indicate the fetus has descended further
into the birth canal toward the pelvic floor. A station of +2 means the presenting part is 2
cm below the anatomical landmark of the ischial spines.
5. A nurse is caring for a client with preeclampsia receiving magnesium sulfate. Which
assessment finding indicates magnesium toxicity?
A. Hyperactive deep tendon reflexes.
B. Respiratory rate of 10 breaths per minute.
C. Urinary output of 40 mL per hour.
D. Increased maternal blood pressure.
Answer: B
Rationale: Magnesium sulfate is a CNS depressant, and toxicity can manifest as respiratory
depression (less than 12 breaths/min). Other signs include loss of deep tendon reflexes and
decreased urinary output. The nurse must have calcium gluconate readily available as the
antidote for magnesium toxicity.
6. A nurse observes a fetal heart rate pattern that shows a sharp decrease from the baseline
and a sharp return, appearing ‘V’ shaped. What is the likely cause?
A. Fetal head compression.
B. Maternal fever or dehydration.
, C. Umbilical cord compression.
D. Chronic uteroplacental insufficiency.
Answer: C
Rationale: Variable decelerations are characterized by a sudden drop and rapid recovery,
often related to umbilical cord compression. These can occur with or without contractions
and are common after the rupture of membranes. Nursing interventions include maternal
position changes to relieve pressure on the cord.
7. The nurse identifies that a client is in the transition phase of the first stage of labor when
which behavior is observed?
A. The client is talkative and excited about the birth.
B. The client feels an uncontrollable urge to push.
C. The client is experiencing mild contractions every 10 minutes.
D. The client becomes irritable and expresses doubt in her ability to continue.
Answer: D
Rationale: The transition phase (8-10 cm dilation) is characterized by intense contractions
and significant emotional changes, including irritability and loss of control. Clients often
experience nausea, vomiting, and a sense of overwhelm during this final part of the first
stage. Supportive care and encouragement are vital nursing roles during this
physiologically demanding phase.
8. What is the priority nursing intervention immediately following an amniotomy (artificial
rupture of membranes)?
A. Document the color, odor, and amount of amniotic fluid.
B. Check the maternal temperature for signs of infection.
C. Perform pericare and change the underpads.
D. Assess the fetal heart rate for at least one full minute.
Answer: D
Rationale: The greatest risk immediately following the rupture of membranes is umbilical
cord prolapse. The nurse must monitor the fetal heart rate to detect decelerations that
would indicate cord compression. If the FHR is stable, then the nurse can proceed with
assessing fluid characteristics and maternal comfort.
9. A client is diagnosed with a placental abruption. Which clinical finding should the nurse
expect?
A. Sudden onset of severe abdominal pain and a board-like abdomen.
