NUR231 Exam 2 V1 | NUR 231
Childbearing & Child Caring Family Exam
Q&A | Galen College of Nursing
1. A nurse is caring for a patient in the active phase of the first stage of labor. Which of the
following cervical dilations would the nurse expect to find?
A. 0-3 cm
B. 4-7 cm
C. 6-10 cm
D. 8-10 cm
Answer: B
Rationale: The active phase of the first stage of labor typically involves cervical dilation
from 4 to 7 cm. This phase is characterized by more regular and stronger contractions
compared to the latent phase. The nurse should monitor progress closely as the patient
transitions toward the second stage.
2. While monitoring a fetal heart rate (FHR) tracing, the nurse notes early decelerations.
What is the primary cause of this finding?
A. Uteroplacental insufficiency
B. Umbilical cord compression
C. Fetal head compression
,D. Fetal hypoxia
Answer: C
Rationale: Early decelerations are caused by fetal head compression during contractions,
which triggers a vagal response. They are considered a benign finding and do not require
clinical intervention. These decelerations usually mirror the contraction, starting and
ending with it.
3. Which of the following interventions is the priority for a nurse who observes late
decelerations on the electronic fetal monitor?
A. Increase the rate of oxytocin infusion
B. Assist the patient into a supine position
C. Perform a vaginal exam immediately
D. Administer oxygen via non-rebreather mask
Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency and are a non-
reassuring sign. Priority interventions include turning the patient to her side, discontinuing
oxytocin, and administering oxygen. These steps aim to improve maternal oxygenation and
placental perfusion.
4. What is the landmark for determining fetal station 0 during a vaginal examination?
A. Iliac crests
, B. Ischial spines
C. Ischial tuberosities
D. Symphysis pubis
Answer: B
Rationale: Fetal station measures the relationship of the presenting part to the maternal
ischial spines. When the presenting part is at the level of the spines, it is documented as
station 0. Positive numbers indicate the fetus has descended below the spines, while
negative numbers mean the fetus is still above them.
5. A patient in labor receives an epidural block. Which side effect should the nurse prioritize
monitoring for immediately following administration?
A. Maternal hypertension
B. Urinary frequency
C. Fetal tachycardia
D. Maternal hypotension
Answer: D
Rationale: Maternal hypotension is a common side effect of epidural anesthesia due to
sympathetic blockade causing vasodilation. This drop in blood pressure can lead to
decreased placental perfusion and fetal distress. Nurses must monitor blood pressure
frequently and be prepared to administer IV fluids or ephedrine.
Childbearing & Child Caring Family Exam
Q&A | Galen College of Nursing
1. A nurse is caring for a patient in the active phase of the first stage of labor. Which of the
following cervical dilations would the nurse expect to find?
A. 0-3 cm
B. 4-7 cm
C. 6-10 cm
D. 8-10 cm
Answer: B
Rationale: The active phase of the first stage of labor typically involves cervical dilation
from 4 to 7 cm. This phase is characterized by more regular and stronger contractions
compared to the latent phase. The nurse should monitor progress closely as the patient
transitions toward the second stage.
2. While monitoring a fetal heart rate (FHR) tracing, the nurse notes early decelerations.
What is the primary cause of this finding?
A. Uteroplacental insufficiency
B. Umbilical cord compression
C. Fetal head compression
,D. Fetal hypoxia
Answer: C
Rationale: Early decelerations are caused by fetal head compression during contractions,
which triggers a vagal response. They are considered a benign finding and do not require
clinical intervention. These decelerations usually mirror the contraction, starting and
ending with it.
3. Which of the following interventions is the priority for a nurse who observes late
decelerations on the electronic fetal monitor?
A. Increase the rate of oxytocin infusion
B. Assist the patient into a supine position
C. Perform a vaginal exam immediately
D. Administer oxygen via non-rebreather mask
Answer: D
Rationale: Late decelerations indicate uteroplacental insufficiency and are a non-
reassuring sign. Priority interventions include turning the patient to her side, discontinuing
oxytocin, and administering oxygen. These steps aim to improve maternal oxygenation and
placental perfusion.
4. What is the landmark for determining fetal station 0 during a vaginal examination?
A. Iliac crests
, B. Ischial spines
C. Ischial tuberosities
D. Symphysis pubis
Answer: B
Rationale: Fetal station measures the relationship of the presenting part to the maternal
ischial spines. When the presenting part is at the level of the spines, it is documented as
station 0. Positive numbers indicate the fetus has descended below the spines, while
negative numbers mean the fetus is still above them.
5. A patient in labor receives an epidural block. Which side effect should the nurse prioritize
monitoring for immediately following administration?
A. Maternal hypertension
B. Urinary frequency
C. Fetal tachycardia
D. Maternal hypotension
Answer: D
Rationale: Maternal hypotension is a common side effect of epidural anesthesia due to
sympathetic blockade causing vasodilation. This drop in blood pressure can lead to
decreased placental perfusion and fetal distress. Nurses must monitor blood pressure
frequently and be prepared to administer IV fluids or ephedrine.
