NSG 432 Exam 2 Nursing Care of the
Childbearing Family – Higher Education
Nursing Curriculum
SECTION I: ANTEPARTUM NURSING CARE
1. A primigravida at 38 weeks of gestation is admitted to the labor and delivery
unit with contractions every 5 minutes, lasting 45 seconds, and moderate
intensity. What is the priority nursing assessment upon admission?
A. Fetal heart rate pattern
B. Maternal blood pressure
C. Cervical dilation and effacement
D. Pain level and coping mechanisms
A BCD
Rationale: The priority assessment upon admission is the fetal heart rate pattern
to establish a baseline and ensure fetal well-being. While maternal vital signs,
cervical status, and pain assessment are all important components of the
admission assessment, fetal heart rate evaluation is the priority to identify any
signs of fetal distress immediately. Cervical assessment should be performed after
the fetal heart rate is evaluated.
2. A nurse is performing a vaginal examination on a client in labor and finds that
the fetal presenting part is 1 cm above the ischial spines. The nurse should
document this finding as which station?
A. -1
B. 0
C. +1
D. +2
A BCD
,Rationale: Station is measured in centimeters above or below the ischial spines.
The ischial spines are designated as station 0. When the presenting part is 1 cm
above the ischial spines, it is documented as station -1. Stations above the ischial
spines are negative numbers, and stations below are positive numbers.
3. A nurse is assessing a client at 34 weeks of gestation who reports sudden onset
of vaginal bleeding accompanied by abdominal pain. The nurse notes the uterus is
rigid and board-like on palpation. Which condition should the nurse suspect?
A. Placenta previa
B. Abruptio placentae
C. Preterm labor
D. Rupture of membranes
B ACD
Rationale: The classic presentation of abruptio placentae includes sudden onset
of vaginal bleeding (which may be concealed), severe abdominal pain, and a rigid,
board-like uterus. Placenta previa typically presents with painless vaginal
bleeding. Preterm labor would present with regular contractions without the rigid
uterine finding.
4. A client at 32 weeks of gestation is diagnosed with gestational diabetes mellitus
(GDM). The nurse should recognize which of the following as the primary goal of
dietary management?
A. Prevent maternal hypoglycemia
B. Maintain blood glucose levels within normal range
C. Promote adequate maternal weight gain
D. Prevent fetal macrosomia
A B C D (Select all that apply)
Rationale: The primary goals of dietary management for GDM include
maintaining blood glucose levels within normal range, preventing maternal
hypoglycemia, promoting adequate maternal weight gain, and preventing fetal
,macrosomia. All options are correct as they represent comprehensive goals of
GDM management.
5. A nurse is performing a prenatal assessment on a client at 28 weeks of
gestation. Which finding should be reported to the healthcare provider
immediately?
A. Fundal height measurement of 28 cm
B. Blood pressure of 138/88 mmHg
C. Weight gain of 0.5 kg in one week
D. Fetal heart rate of 140 bpm
B ACD
Rationale: A blood pressure of 138/88 mmHg is elevated and should be reported
as it may indicate the development of gestational hypertension or preeclampsia.
Fundal height of 28 cm at 28 weeks is appropriate. Weight gain of 0.5 kg in one
week is within expected parameters. Fetal heart rate of 140 bpm is normal.
6. The nurse is educating a pregnant client about the signs of preterm labor.
Which of the following should the nurse include in the teaching? (Select all that
apply)
A. Menstrual-like cramping
B. Low, dull backache
C. Pelvic pressure
D. Increased vaginal discharge
E. Contractions that are irregular and painless
ABCD E
Rationale: Signs of preterm labor include menstrual-like cramping, low dull
backache, pelvic pressure, and increased vaginal discharge. Contractions in
preterm labor are typically regular and may be painful, not irregular and painless.
Irregular painless contractions are more consistent with Braxton-Hicks
contractions.
, 7. A client at 39 weeks of gestation with a history of herpes simplex virus (HSV)
infection has active genital lesions. The nurse anticipates which route of delivery?
A. Vaginal delivery with antiviral therapy
B. Cesarean section
C. Vaginal delivery with rupture of membranes delayed
D. Vacuum-assisted vaginal delivery
B ACD
Rationale: A cesarean section is recommended for clients with active genital
herpes lesions at the time of labor to prevent neonatal transmission of the virus.
Vaginal delivery poses a significant risk of neonatal herpes infection, which can be
life-threatening.
8. A nurse is assessing a newborn immediately after birth and notes acrocyanosis.
The nurse understands that this finding:
A. Indicates respiratory distress
B. Is a normal finding in the first 24 hours
C. Requires immediate intervention
D. Suggests a cardiac anomaly
B ACD
Rationale: Acrocyanosis—bluish discoloration of the hands and feet—is a normal
finding in the newborn during the first 24 hours of life as the circulatory system
adapts to extrauterine life. Central cyanosis (cyanosis of the trunk and mucous
membranes) would be concerning and require immediate intervention.
9. A client at 36 weeks of gestation presents with complaints of severe headache,
visual disturbances, and epigastric pain. Her blood pressure is 160/100 mmHg.
Which medication should the nurse anticipate administering?
Childbearing Family – Higher Education
Nursing Curriculum
SECTION I: ANTEPARTUM NURSING CARE
1. A primigravida at 38 weeks of gestation is admitted to the labor and delivery
unit with contractions every 5 minutes, lasting 45 seconds, and moderate
intensity. What is the priority nursing assessment upon admission?
A. Fetal heart rate pattern
B. Maternal blood pressure
C. Cervical dilation and effacement
D. Pain level and coping mechanisms
A BCD
Rationale: The priority assessment upon admission is the fetal heart rate pattern
to establish a baseline and ensure fetal well-being. While maternal vital signs,
cervical status, and pain assessment are all important components of the
admission assessment, fetal heart rate evaluation is the priority to identify any
signs of fetal distress immediately. Cervical assessment should be performed after
the fetal heart rate is evaluated.
2. A nurse is performing a vaginal examination on a client in labor and finds that
the fetal presenting part is 1 cm above the ischial spines. The nurse should
document this finding as which station?
A. -1
B. 0
C. +1
D. +2
A BCD
,Rationale: Station is measured in centimeters above or below the ischial spines.
The ischial spines are designated as station 0. When the presenting part is 1 cm
above the ischial spines, it is documented as station -1. Stations above the ischial
spines are negative numbers, and stations below are positive numbers.
3. A nurse is assessing a client at 34 weeks of gestation who reports sudden onset
of vaginal bleeding accompanied by abdominal pain. The nurse notes the uterus is
rigid and board-like on palpation. Which condition should the nurse suspect?
A. Placenta previa
B. Abruptio placentae
C. Preterm labor
D. Rupture of membranes
B ACD
Rationale: The classic presentation of abruptio placentae includes sudden onset
of vaginal bleeding (which may be concealed), severe abdominal pain, and a rigid,
board-like uterus. Placenta previa typically presents with painless vaginal
bleeding. Preterm labor would present with regular contractions without the rigid
uterine finding.
4. A client at 32 weeks of gestation is diagnosed with gestational diabetes mellitus
(GDM). The nurse should recognize which of the following as the primary goal of
dietary management?
A. Prevent maternal hypoglycemia
B. Maintain blood glucose levels within normal range
C. Promote adequate maternal weight gain
D. Prevent fetal macrosomia
A B C D (Select all that apply)
Rationale: The primary goals of dietary management for GDM include
maintaining blood glucose levels within normal range, preventing maternal
hypoglycemia, promoting adequate maternal weight gain, and preventing fetal
,macrosomia. All options are correct as they represent comprehensive goals of
GDM management.
5. A nurse is performing a prenatal assessment on a client at 28 weeks of
gestation. Which finding should be reported to the healthcare provider
immediately?
A. Fundal height measurement of 28 cm
B. Blood pressure of 138/88 mmHg
C. Weight gain of 0.5 kg in one week
D. Fetal heart rate of 140 bpm
B ACD
Rationale: A blood pressure of 138/88 mmHg is elevated and should be reported
as it may indicate the development of gestational hypertension or preeclampsia.
Fundal height of 28 cm at 28 weeks is appropriate. Weight gain of 0.5 kg in one
week is within expected parameters. Fetal heart rate of 140 bpm is normal.
6. The nurse is educating a pregnant client about the signs of preterm labor.
Which of the following should the nurse include in the teaching? (Select all that
apply)
A. Menstrual-like cramping
B. Low, dull backache
C. Pelvic pressure
D. Increased vaginal discharge
E. Contractions that are irregular and painless
ABCD E
Rationale: Signs of preterm labor include menstrual-like cramping, low dull
backache, pelvic pressure, and increased vaginal discharge. Contractions in
preterm labor are typically regular and may be painful, not irregular and painless.
Irregular painless contractions are more consistent with Braxton-Hicks
contractions.
, 7. A client at 39 weeks of gestation with a history of herpes simplex virus (HSV)
infection has active genital lesions. The nurse anticipates which route of delivery?
A. Vaginal delivery with antiviral therapy
B. Cesarean section
C. Vaginal delivery with rupture of membranes delayed
D. Vacuum-assisted vaginal delivery
B ACD
Rationale: A cesarean section is recommended for clients with active genital
herpes lesions at the time of labor to prevent neonatal transmission of the virus.
Vaginal delivery poses a significant risk of neonatal herpes infection, which can be
life-threatening.
8. A nurse is assessing a newborn immediately after birth and notes acrocyanosis.
The nurse understands that this finding:
A. Indicates respiratory distress
B. Is a normal finding in the first 24 hours
C. Requires immediate intervention
D. Suggests a cardiac anomaly
B ACD
Rationale: Acrocyanosis—bluish discoloration of the hands and feet—is a normal
finding in the newborn during the first 24 hours of life as the circulatory system
adapts to extrauterine life. Central cyanosis (cyanosis of the trunk and mucous
membranes) would be concerning and require immediate intervention.
9. A client at 36 weeks of gestation presents with complaints of severe headache,
visual disturbances, and epigastric pain. Her blood pressure is 160/100 mmHg.
Which medication should the nurse anticipate administering?
