NUR 231 Exam 1 Actual Exam V3 | NUR 231 Childbearing & Child
Caring Family (NUR231 Exam 1) | Galen College of Nursing
1. A nurse is assessing a client who is at 30 weeks of gestation. Which of the following
findings should the nurse report to the provider immediately?
A. Periodic numbness and tingling of the fingers
B. Hyperpigmentation of the cheeks and nose
C. Increase in white vaginal discharge
D. Swelling of the face and around the eyes
Answer: D
Rationale: Facial edema is a potential sign of preeclampsia and requires immediate follow-
up to check blood pressure and urine protein. Numbness in fingers is often related to
carpal tunnel syndrome caused by fluid retention, which is common. Cloasma and
increased leukorrhea are normal physiological changes during the third trimester of
pregnancy.
2. A nurse is calculating the estimated date of delivery (EDD) for a client whose last menstrual
period began on May 10th. Using Naegele’s rule, what is the EDD?
A. February 3rd
B. February 17th
C. January 17th
D. March 10th
Answer: B
Rationale: Naegele’s rule involves subtracting 3 months from the first day of the last
menstrual period and adding 7 days and 1 year. For a May 10th start date, subtracting 3
months brings us to February, and adding 7 days makes it February 17th. This calculation
assumes a standard 28-day cycle and is the primary clinical tool for dating pregnancy.
3. A client presents with her first pregnancy and is currently at 12 weeks gestation. She has a
history of one miscarriage at 8 weeks and one elective abortion at 6 weeks. What is her
GTPAL?
A. G1, T0, P0, A0, L0
B. G3, T0, P0, A2, L0
C. G3, T1, P0, A2, L1
D. G2, T0, P0, A1, L0
,Answer: B
Rationale: G stands for Gravida (total pregnancies), which includes the current one plus
the two losses, totaling 3. T (Term) and P (Preterm) are 0 because no pregnancy reached at
least 20 weeks. A (Abortion/Miscarriage) is 2, and L (Living children) is 0, making the
correct sequence G3, T0, P0, A2, L0.
4. Which of the following assessment findings is considered a positive sign of pregnancy?
A. A positive serum pregnancy test
B. Amenorrhea and morning sickness
C. Hegar’s sign upon pelvic examination
D. Fetal heart tones heard via Doppler
Answer: D
Rationale: Positive signs of pregnancy are those that can only be attributed to a fetus, such
as fetal heart sounds, visualization by ultrasound, or fetal movement felt by a provider. A
pregnancy test is a probable sign because certain tumors can produce hCG. Hegar’s sign is a
probable sign, and amenorrhea is a presumptive sign subjective to the mother.
5. A nurse is teaching a pregnant client about nutrition. Which statement by the client
indicates a need for further teaching regarding folic acid?
A. I should take folic acid to prevent neural tube defects
B. I can find folic acid in green leafy vegetables
C. Folic acid is important for the development of the spinal cord
D. I only need to take folic acid during the third trimester
Answer: D
Rationale: Folic acid is most critical in the first trimester, particularly during the first few
weeks when the neural tube closes. Clients are encouraged to take folic acid even before
conception to ensure adequate levels. The other statements are correct because folic acid
prevents defects like spina bifida and is found in foods like spinach and fortified cereals.
6. During a prenatal visit, a client at 28 weeks gestation reports feeling dizzy and faint when
lying on her back. What is the most appropriate nursing intervention?
A. Advise the client to lie on her left side
B. Assess the client’s blood glucose levels
C. Instruct the client to increase her sodium intake
D. Place the client in the Trendelenburg position
Answer: A
, Rationale: This client is experiencing supine hypotensive syndrome, caused by the heavy
uterus compressing the inferior vena cava. Lying on the left side displaces the uterus and
restores blood flow to the heart and placenta. This is a standard education point for all
pregnant women in the second and third trimesters.
7. A nurse is reviewing a reactive non-stress test (NST). Which of the following criteria defines
a reactive NST?
A. Occasional variable decelerations lasting less than 10 seconds
B. Presence of late decelerations with every contraction
C. A fetal heart rate baseline of 110 with no variability
D. Two fetal heart rate accelerations of 15 bpm for 15 seconds in 20 minutes
Answer: D
Rationale: A reactive NST is a sign of fetal well-being, indicating an intact central nervous
system and adequate oxygenation. It requires at least two accelerations of 15 beats per
minute above baseline lasting at least 15 seconds within a 20-minute window. A non-
reactive test would require further testing, such as a biophysical profile (BPP).
8. A client at 36 weeks gestation is diagnosed with mild preeclampsia. Which of the following
home care instructions should the nurse include?
A. Restrict fluid intake to 1 liter per day
B. Increase intake of high-protein, low-fat foods
C. Monitor fetal kick counts daily
D. Perform vigorous aerobic exercise to improve circulation
Answer: C
Rationale: Fetal kick counts are a vital way for a client with preeclampsia to monitor fetal
well-being at home. Clients should also be taught to monitor for worsening symptoms like
headache, vision changes, or epigastric pain. Resting in a side-lying position is
recommended rather than vigorous exercise, which could increase blood pressure.
9. A nurse is administering magnesium sulfate to a client with severe preeclampsia. Which
finding is the first sign of magnesium toxicity?
A. Increased urinary output
B. Elevated blood pressure
C. Respiratory rate of 16 breaths per minute
D. Loss of deep tendon reflexes
Answer: D
Caring Family (NUR231 Exam 1) | Galen College of Nursing
1. A nurse is assessing a client who is at 30 weeks of gestation. Which of the following
findings should the nurse report to the provider immediately?
A. Periodic numbness and tingling of the fingers
B. Hyperpigmentation of the cheeks and nose
C. Increase in white vaginal discharge
D. Swelling of the face and around the eyes
Answer: D
Rationale: Facial edema is a potential sign of preeclampsia and requires immediate follow-
up to check blood pressure and urine protein. Numbness in fingers is often related to
carpal tunnel syndrome caused by fluid retention, which is common. Cloasma and
increased leukorrhea are normal physiological changes during the third trimester of
pregnancy.
2. A nurse is calculating the estimated date of delivery (EDD) for a client whose last menstrual
period began on May 10th. Using Naegele’s rule, what is the EDD?
A. February 3rd
B. February 17th
C. January 17th
D. March 10th
Answer: B
Rationale: Naegele’s rule involves subtracting 3 months from the first day of the last
menstrual period and adding 7 days and 1 year. For a May 10th start date, subtracting 3
months brings us to February, and adding 7 days makes it February 17th. This calculation
assumes a standard 28-day cycle and is the primary clinical tool for dating pregnancy.
3. A client presents with her first pregnancy and is currently at 12 weeks gestation. She has a
history of one miscarriage at 8 weeks and one elective abortion at 6 weeks. What is her
GTPAL?
A. G1, T0, P0, A0, L0
B. G3, T0, P0, A2, L0
C. G3, T1, P0, A2, L1
D. G2, T0, P0, A1, L0
,Answer: B
Rationale: G stands for Gravida (total pregnancies), which includes the current one plus
the two losses, totaling 3. T (Term) and P (Preterm) are 0 because no pregnancy reached at
least 20 weeks. A (Abortion/Miscarriage) is 2, and L (Living children) is 0, making the
correct sequence G3, T0, P0, A2, L0.
4. Which of the following assessment findings is considered a positive sign of pregnancy?
A. A positive serum pregnancy test
B. Amenorrhea and morning sickness
C. Hegar’s sign upon pelvic examination
D. Fetal heart tones heard via Doppler
Answer: D
Rationale: Positive signs of pregnancy are those that can only be attributed to a fetus, such
as fetal heart sounds, visualization by ultrasound, or fetal movement felt by a provider. A
pregnancy test is a probable sign because certain tumors can produce hCG. Hegar’s sign is a
probable sign, and amenorrhea is a presumptive sign subjective to the mother.
5. A nurse is teaching a pregnant client about nutrition. Which statement by the client
indicates a need for further teaching regarding folic acid?
A. I should take folic acid to prevent neural tube defects
B. I can find folic acid in green leafy vegetables
C. Folic acid is important for the development of the spinal cord
D. I only need to take folic acid during the third trimester
Answer: D
Rationale: Folic acid is most critical in the first trimester, particularly during the first few
weeks when the neural tube closes. Clients are encouraged to take folic acid even before
conception to ensure adequate levels. The other statements are correct because folic acid
prevents defects like spina bifida and is found in foods like spinach and fortified cereals.
6. During a prenatal visit, a client at 28 weeks gestation reports feeling dizzy and faint when
lying on her back. What is the most appropriate nursing intervention?
A. Advise the client to lie on her left side
B. Assess the client’s blood glucose levels
C. Instruct the client to increase her sodium intake
D. Place the client in the Trendelenburg position
Answer: A
, Rationale: This client is experiencing supine hypotensive syndrome, caused by the heavy
uterus compressing the inferior vena cava. Lying on the left side displaces the uterus and
restores blood flow to the heart and placenta. This is a standard education point for all
pregnant women in the second and third trimesters.
7. A nurse is reviewing a reactive non-stress test (NST). Which of the following criteria defines
a reactive NST?
A. Occasional variable decelerations lasting less than 10 seconds
B. Presence of late decelerations with every contraction
C. A fetal heart rate baseline of 110 with no variability
D. Two fetal heart rate accelerations of 15 bpm for 15 seconds in 20 minutes
Answer: D
Rationale: A reactive NST is a sign of fetal well-being, indicating an intact central nervous
system and adequate oxygenation. It requires at least two accelerations of 15 beats per
minute above baseline lasting at least 15 seconds within a 20-minute window. A non-
reactive test would require further testing, such as a biophysical profile (BPP).
8. A client at 36 weeks gestation is diagnosed with mild preeclampsia. Which of the following
home care instructions should the nurse include?
A. Restrict fluid intake to 1 liter per day
B. Increase intake of high-protein, low-fat foods
C. Monitor fetal kick counts daily
D. Perform vigorous aerobic exercise to improve circulation
Answer: C
Rationale: Fetal kick counts are a vital way for a client with preeclampsia to monitor fetal
well-being at home. Clients should also be taught to monitor for worsening symptoms like
headache, vision changes, or epigastric pain. Resting in a side-lying position is
recommended rather than vigorous exercise, which could increase blood pressure.
9. A nurse is administering magnesium sulfate to a client with severe preeclampsia. Which
finding is the first sign of magnesium toxicity?
A. Increased urinary output
B. Elevated blood pressure
C. Respiratory rate of 16 breaths per minute
D. Loss of deep tendon reflexes
Answer: D
