NSG 432 Exam 2 V3 | NSG 432 Maternal-
Newborn Nursing / OB/GYN | Actual Q&A
with Rationale (NSG432 Exam 2) | Grand
Canyon University
1. A nurse is assessing a client who is at 36 weeks of gestation and reports a sudden gush of
vaginal fluid. Which of the following actions should the nurse take first to evaluate for
spontaneous rupture of membranes?
A. Perform a sterile vaginal examination to check for dilation.
B. Obtain a urine specimen for a standard urinalysis.
C. Check the vaginal fluid with nitrazine paper for alkalinity.
D. Observe for the presence of a mucus plug.
Correct Answer: C
The first action to confirm the rupture of membranes is to assess the pH of the fluid using
nitrazine paper. Amniotic fluid is alkaline, causing the paper to turn blue, whereas vaginal
secretions are typically acidic. This assessment is non-invasive and provides immediate
data before proceeding to more invasive examinations like a sterile speculum test or
vaginal exam.
,2. A nurse is providing education to a group of pregnant clients about the signs of impending
labor. Which of the following signs should the nurse include in the teaching? (Select All That
Apply)
A. Weight gain of 1 to 3 pounds
B. Nesting (surge in energy)
C. Bloody show
D. Ruputure of membranes
E. Lightening
F. Decreased urinary frequency
Correct Answer: B,C,D,E
Impending labor is characterized by several physiological changes including lightening,
where the fetus descends into the pelvis, and a sudden surge of energy often referred to as
nesting. The presence of a bloody show indicates cervical changes and the rupture of
membranes is a definitive sign that labor is near or starting. Weight loss, not gain, and
increased urinary frequency are more common signs of late pregnancy approaching labor.
3. A nurse is monitoring a client in labor who has an external fetal monitor. The nurse notes a
pattern of early decelerations on the tracing. Which of the following actions should the nurse
take?
A. Administer oxygen via a nonrebreather mask at 10 L/min.
B. Continue to monitor the client and document the findings.
,C. Prepare the client for an emergency cesarean birth.
D. Place the client in a knee-chest position immediately.
Correct Answer: B
Early decelerations are considered a reassuring fetal heart rate pattern caused by fetal
head compression during contractions. They typically mirror the contraction and return to
baseline at the end of the contraction. Because they are not indicative of fetal distress or
hypoxia, the nurse should continue standard monitoring and documentation without
requiring aggressive intervention.
4. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings is the priority for the nurse to report to the provider?
A. Maternal heart rate of 90/min
B. Urinary output of 40 mL/hr
C. Deep tendon reflexes of 2+
D. Respiratory rate of 10/min
Correct Answer: D
Magnesium sulfate toxicity can cause central nervous system depression, leading to a
decreased respiratory rate. A respiratory rate below 12/min is a critical indicator of
toxicity and requires the nurse to stop the infusion and notify the provider immediately.
Other signs of toxicity include loss of deep tendon reflexes and a significant drop in urinary
output below 30 mL/hr.
, 5. A nurse is caring for a client in the active phase of labor. The client’s cervix is dilated to 5
cm and contractions are occurring every 3 minutes. Which of the following is an appropriate
nursing intervention?
A. Instruct the client to begin pushing.
B. Perform a vaginal exam every 15 minutes.
C. Prepare for the delivery of the placenta.
D. Encourage the client to change positions frequently.
Correct Answer: D
During the active phase of labor, frequent position changes help promote fetal descent and
improve maternal comfort. The client should not push until the cervix is fully dilated to 10
cm to avoid cervical edema or tearing. Frequent vaginal exams are discouraged unless
necessary to minimize the risk of infection after the rupture of membranes.
6. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. Nasal flaring and chest retractions
C. Respiratory rate of 50/min
D. Milia on the bridge of the nose
Correct Answer: B
Newborn Nursing / OB/GYN | Actual Q&A
with Rationale (NSG432 Exam 2) | Grand
Canyon University
1. A nurse is assessing a client who is at 36 weeks of gestation and reports a sudden gush of
vaginal fluid. Which of the following actions should the nurse take first to evaluate for
spontaneous rupture of membranes?
A. Perform a sterile vaginal examination to check for dilation.
B. Obtain a urine specimen for a standard urinalysis.
C. Check the vaginal fluid with nitrazine paper for alkalinity.
D. Observe for the presence of a mucus plug.
Correct Answer: C
The first action to confirm the rupture of membranes is to assess the pH of the fluid using
nitrazine paper. Amniotic fluid is alkaline, causing the paper to turn blue, whereas vaginal
secretions are typically acidic. This assessment is non-invasive and provides immediate
data before proceeding to more invasive examinations like a sterile speculum test or
vaginal exam.
,2. A nurse is providing education to a group of pregnant clients about the signs of impending
labor. Which of the following signs should the nurse include in the teaching? (Select All That
Apply)
A. Weight gain of 1 to 3 pounds
B. Nesting (surge in energy)
C. Bloody show
D. Ruputure of membranes
E. Lightening
F. Decreased urinary frequency
Correct Answer: B,C,D,E
Impending labor is characterized by several physiological changes including lightening,
where the fetus descends into the pelvis, and a sudden surge of energy often referred to as
nesting. The presence of a bloody show indicates cervical changes and the rupture of
membranes is a definitive sign that labor is near or starting. Weight loss, not gain, and
increased urinary frequency are more common signs of late pregnancy approaching labor.
3. A nurse is monitoring a client in labor who has an external fetal monitor. The nurse notes a
pattern of early decelerations on the tracing. Which of the following actions should the nurse
take?
A. Administer oxygen via a nonrebreather mask at 10 L/min.
B. Continue to monitor the client and document the findings.
,C. Prepare the client for an emergency cesarean birth.
D. Place the client in a knee-chest position immediately.
Correct Answer: B
Early decelerations are considered a reassuring fetal heart rate pattern caused by fetal
head compression during contractions. They typically mirror the contraction and return to
baseline at the end of the contraction. Because they are not indicative of fetal distress or
hypoxia, the nurse should continue standard monitoring and documentation without
requiring aggressive intervention.
4. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings is the priority for the nurse to report to the provider?
A. Maternal heart rate of 90/min
B. Urinary output of 40 mL/hr
C. Deep tendon reflexes of 2+
D. Respiratory rate of 10/min
Correct Answer: D
Magnesium sulfate toxicity can cause central nervous system depression, leading to a
decreased respiratory rate. A respiratory rate below 12/min is a critical indicator of
toxicity and requires the nurse to stop the infusion and notify the provider immediately.
Other signs of toxicity include loss of deep tendon reflexes and a significant drop in urinary
output below 30 mL/hr.
, 5. A nurse is caring for a client in the active phase of labor. The client’s cervix is dilated to 5
cm and contractions are occurring every 3 minutes. Which of the following is an appropriate
nursing intervention?
A. Instruct the client to begin pushing.
B. Perform a vaginal exam every 15 minutes.
C. Prepare for the delivery of the placenta.
D. Encourage the client to change positions frequently.
Correct Answer: D
During the active phase of labor, frequent position changes help promote fetal descent and
improve maternal comfort. The client should not push until the cervix is fully dilated to 10
cm to avoid cervical edema or tearing. Frequent vaginal exams are discouraged unless
necessary to minimize the risk of infection after the rupture of membranes.
6. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. Nasal flaring and chest retractions
C. Respiratory rate of 50/min
D. Milia on the bridge of the nose
Correct Answer: B
