NUR231 Exam 2 V2 | NUR 231
Childbearing & Child Caring Family Exam
Q&A | Galen College of Nursing
1. A nurse is caring for a client in the active phase of labor who is receiving oxytocin (Pitocin).
The nurse notes fetal heart rate decelerations that begin after the peak of the contraction
and return to baseline after the contraction ends. What is the priority nursing action?
A. Increase the oxytocin infusion rate.
B. Perform a vaginal exam to check for cord prolapse.
C. Prepare for immediate forceps delivery.
D. Turn the client to the left side and stop the oxytocin.
Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency. The priority is to stop
the oxytocin to reduce uterine activity and turn the client to the side to improve blood flow
to the placenta. This nursing intervention is critical for fetal oxygenation.
2. Which Bishop score would indicate that the client’s cervix is most favorable for the
induction of labor?
A. Bishop score of 2
B. Bishop score of 9
C. Bishop score of 4
,D. Bishop score of 5
Answer: B
Rationale: A Bishop score of 8 or greater typically indicates that the cervix is soft, dilated,
and ready for induction, suggesting a higher likelihood of a successful vaginal delivery.
Scores lower than 6 often require cervical ripening agents. The Bishop score evaluates five
factors: dilation, effacement, station, consistency, and position.
3. The nurse is assessing a client for postpartum hemorrhage. Which finding should the nurse
recognize as the most common cause of early postpartum hemorrhage?
A. Retained placental fragments
B. Vaginal lacerations
C. Uterine atony
D. Hematoma formation
Answer: C
Rationale: Uterine atony, or the failure of the uterus to contract after birth, is the leading
cause of postpartum hemorrhage. When the uterus is boggy and relaxed, the blood vessels
at the placental site remain open, leading to rapid blood loss. This requires immediate
fundal massage and potentially uterotonic medications.
4. A client is in the second stage of labor, and the nurse notes the fetal head emerges but
then retracts against the perineum (turtle sign). Which action should the nurse take first?
A. Apply fundal pressure immediately.
, B. Prepare the client for a cesarean section.
C. Perform the McRoberts maneuver.
D. Administer a bolus of IV fluids.
Answer: C
Rationale: The ‘turtle sign’ is a classic indicator of shoulder dystocia. The McRoberts
maneuver, which involves flexing the mother’s thighs toward her abdomen, helps open the
pelvic outlet. Fundal pressure is strictly contraindicated in this situation as it can further
wedge the shoulder against the pubic bone.
5. A newborn’s APGAR score at 1 minute is 8. The score is based on which five parameters?
A. Heart rate, respiratory effort, muscle tone, reflex irritability, and color
B. Weight, length, head circumference, temperature, and heart rate
C. Heart rate, oxygen saturation, blood pressure, muscle tone, and color
D. Respiratory rate, heart rate, temperature, reflex irritability, and glucose level
Answer: A
Rationale: The APGAR score is a standardized assessment tool used to evaluate a
newborn’s transition to extrauterine life at 1 and 5 minutes. It evaluates heart rate,
respiratory effort, muscle tone, reflex irritability (grimace), and skin color. Each category is
scored from 0 to 2, with a maximum total score of 10.
Childbearing & Child Caring Family Exam
Q&A | Galen College of Nursing
1. A nurse is caring for a client in the active phase of labor who is receiving oxytocin (Pitocin).
The nurse notes fetal heart rate decelerations that begin after the peak of the contraction
and return to baseline after the contraction ends. What is the priority nursing action?
A. Increase the oxytocin infusion rate.
B. Perform a vaginal exam to check for cord prolapse.
C. Prepare for immediate forceps delivery.
D. Turn the client to the left side and stop the oxytocin.
Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency. The priority is to stop
the oxytocin to reduce uterine activity and turn the client to the side to improve blood flow
to the placenta. This nursing intervention is critical for fetal oxygenation.
2. Which Bishop score would indicate that the client’s cervix is most favorable for the
induction of labor?
A. Bishop score of 2
B. Bishop score of 9
C. Bishop score of 4
,D. Bishop score of 5
Answer: B
Rationale: A Bishop score of 8 or greater typically indicates that the cervix is soft, dilated,
and ready for induction, suggesting a higher likelihood of a successful vaginal delivery.
Scores lower than 6 often require cervical ripening agents. The Bishop score evaluates five
factors: dilation, effacement, station, consistency, and position.
3. The nurse is assessing a client for postpartum hemorrhage. Which finding should the nurse
recognize as the most common cause of early postpartum hemorrhage?
A. Retained placental fragments
B. Vaginal lacerations
C. Uterine atony
D. Hematoma formation
Answer: C
Rationale: Uterine atony, or the failure of the uterus to contract after birth, is the leading
cause of postpartum hemorrhage. When the uterus is boggy and relaxed, the blood vessels
at the placental site remain open, leading to rapid blood loss. This requires immediate
fundal massage and potentially uterotonic medications.
4. A client is in the second stage of labor, and the nurse notes the fetal head emerges but
then retracts against the perineum (turtle sign). Which action should the nurse take first?
A. Apply fundal pressure immediately.
, B. Prepare the client for a cesarean section.
C. Perform the McRoberts maneuver.
D. Administer a bolus of IV fluids.
Answer: C
Rationale: The ‘turtle sign’ is a classic indicator of shoulder dystocia. The McRoberts
maneuver, which involves flexing the mother’s thighs toward her abdomen, helps open the
pelvic outlet. Fundal pressure is strictly contraindicated in this situation as it can further
wedge the shoulder against the pubic bone.
5. A newborn’s APGAR score at 1 minute is 8. The score is based on which five parameters?
A. Heart rate, respiratory effort, muscle tone, reflex irritability, and color
B. Weight, length, head circumference, temperature, and heart rate
C. Heart rate, oxygen saturation, blood pressure, muscle tone, and color
D. Respiratory rate, heart rate, temperature, reflex irritability, and glucose level
Answer: A
Rationale: The APGAR score is a standardized assessment tool used to evaluate a
newborn’s transition to extrauterine life at 1 and 5 minutes. It evaluates heart rate,
respiratory effort, muscle tone, reflex irritability (grimace), and skin color. Each category is
scored from 0 to 2, with a maximum total score of 10.
