NUR 418 / NUR 415 Exam 2 V2 | NUR 418 /
NUR 415 Nursing Care of the Childbearing
& Childrearing Family | Actual Q&A with
Rationale (NUR418/NUR415 Exam 2) |
Concordia
1. A nurse is caring for a client in the active phase of the first stage of labor. The client’s cervix
is dilated to 5 cm, and the contractions are every 3 minutes, lasting 45 seconds. Which of the
following nursing actions is the priority?
A. Perform a sterile vaginal exam to check for crowning.
B. Administer an opioid analgesic as requested.
C. Encourage the client to void every 1 to 2 hours.
D. Assist the client into a supine position for comfort.
Correct Answer: C
Explanation; A full bladder can impede fetal descent and cause unnecessary discomfort
during the active phase of labor. Encouraging the client to void regularly promotes the
progress of labor and prevents bladder trauma. The supine position should be avoided to
prevent vena cava compression and maternal hypotension.
2. A nurse is monitoring a fetal heart rate (FHR) tracing and notes early decelerations. Which
of the following actions should the nurse take?
A. Continue to monitor the FHR pattern as this is a benign finding.
,B. Administer oxygen at 10 L/min via nonrebreather mask.
C. Increase the rate of the intravenous infusion.
D. Prepare the client for an emergency cesarean birth.
Correct Answer: A
Explanation; Early decelerations are caused by fetal head compression and are considered
a reassuring/benign finding. They typically mirror the contraction and do not require
medical intervention. The nurse should continue to monitor the labor progress and fetal
well-being as per standard protocol.
3. A nurse is assessing a client who is 2 hours postpartum and identifies a boggy uterus and
heavy lochia rubra. Which of the following medications should the nurse anticipate
administering? (Select All That Apply)
A. Oxytocin
B. Methylergonovine
C. Terbutaline
D. Misoprostol
E. Carboprost tromethamine
F. Magnesium Sulfate
Correct Answer: A, B, D, E
, Explanation; Oxytocin, Methylergonovine, Misoprostol, and Carboprost are all uterotonic
medications used to manage postpartum hemorrhage by promoting uterine contractions.
Terbutaline and Magnesium Sulfate are tocolytics used to relax the uterus and are
contraindicated in hemorrhage. Nurses must check blood pressure before giving
Methylergonovine as it can cause hypertension.
4. A newborn is placed under a radiant warmer for assessment. Which mechanism of heat
loss is being prevented by the use of the radiant warmer?
A. Radiation
B. Convection
C. Evaporation
D. Conduction
Correct Answer: A
Explanation; Radiation is the loss of body heat to cooler solid surfaces that are in
proximity but not in direct contact with the newborn. A radiant warmer provides a heat
source to counter this specific type of loss. Conduction involves direct contact, while
convection involves air currents.
5. A nurse is caring for a client with preeclampsia receiving magnesium sulfate. The nurse
notes a respiratory rate of 10/min and absent deep tendon reflexes. Which action is the
priority?
A. Decrease the magnesium sulfate infusion rate by half.
NUR 415 Nursing Care of the Childbearing
& Childrearing Family | Actual Q&A with
Rationale (NUR418/NUR415 Exam 2) |
Concordia
1. A nurse is caring for a client in the active phase of the first stage of labor. The client’s cervix
is dilated to 5 cm, and the contractions are every 3 minutes, lasting 45 seconds. Which of the
following nursing actions is the priority?
A. Perform a sterile vaginal exam to check for crowning.
B. Administer an opioid analgesic as requested.
C. Encourage the client to void every 1 to 2 hours.
D. Assist the client into a supine position for comfort.
Correct Answer: C
Explanation; A full bladder can impede fetal descent and cause unnecessary discomfort
during the active phase of labor. Encouraging the client to void regularly promotes the
progress of labor and prevents bladder trauma. The supine position should be avoided to
prevent vena cava compression and maternal hypotension.
2. A nurse is monitoring a fetal heart rate (FHR) tracing and notes early decelerations. Which
of the following actions should the nurse take?
A. Continue to monitor the FHR pattern as this is a benign finding.
,B. Administer oxygen at 10 L/min via nonrebreather mask.
C. Increase the rate of the intravenous infusion.
D. Prepare the client for an emergency cesarean birth.
Correct Answer: A
Explanation; Early decelerations are caused by fetal head compression and are considered
a reassuring/benign finding. They typically mirror the contraction and do not require
medical intervention. The nurse should continue to monitor the labor progress and fetal
well-being as per standard protocol.
3. A nurse is assessing a client who is 2 hours postpartum and identifies a boggy uterus and
heavy lochia rubra. Which of the following medications should the nurse anticipate
administering? (Select All That Apply)
A. Oxytocin
B. Methylergonovine
C. Terbutaline
D. Misoprostol
E. Carboprost tromethamine
F. Magnesium Sulfate
Correct Answer: A, B, D, E
, Explanation; Oxytocin, Methylergonovine, Misoprostol, and Carboprost are all uterotonic
medications used to manage postpartum hemorrhage by promoting uterine contractions.
Terbutaline and Magnesium Sulfate are tocolytics used to relax the uterus and are
contraindicated in hemorrhage. Nurses must check blood pressure before giving
Methylergonovine as it can cause hypertension.
4. A newborn is placed under a radiant warmer for assessment. Which mechanism of heat
loss is being prevented by the use of the radiant warmer?
A. Radiation
B. Convection
C. Evaporation
D. Conduction
Correct Answer: A
Explanation; Radiation is the loss of body heat to cooler solid surfaces that are in
proximity but not in direct contact with the newborn. A radiant warmer provides a heat
source to counter this specific type of loss. Conduction involves direct contact, while
convection involves air currents.
5. A nurse is caring for a client with preeclampsia receiving magnesium sulfate. The nurse
notes a respiratory rate of 10/min and absent deep tendon reflexes. Which action is the
priority?
A. Decrease the magnesium sulfate infusion rate by half.
