NUR 230 Exam 2 V1 | NUR 230 The
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 2) | Galen
College of Nursing
1. A nurse is monitoring a client in labor who is receiving an oxytocin infusion. The nurse
notes that the client is experiencing contractions every 90 seconds, lasting 70 to 80 seconds.
What is the priority nursing action?
A. Reposition the client to a side-lying position.
B. Administer oxygen via a non-rebreather mask.
C. Discontinue the oxytocin infusion immediately.
D. Increase the rate of the maintenance IV fluids.
Answer: C
Rationale: The client is exhibiting signs of uterine tachysystole, which is defined as more
than 5 contractions in a 10-minute period or contractions occurring less than 2 minutes
apart. The immediate priority is to stop the oxytocin to prevent uterine rupture and fetal
distress. Once the infusion is stopped, the nurse should then implement secondary
measures such as repositioning and oxygen therapy.
,2. A nurse is caring for a client at 34 weeks of gestation who has been diagnosed with severe
preeclampsia. Which of the following findings should the nurse report to the provider
immediately?
A. 1+ pitting edema in the lower extremities.
B. Blood pressure of 148/92 mmHg.
C. Epigastric pain or right upper quadrant pain.
D. Urinary output of 40 mL per hour.
Answer: C
Rationale: Epigastric pain is a warning sign of impending hepatic involvement or HELLP
syndrome, which is a severe complication of preeclampsia. This symptom often precedes a
seizure (eclampsia) due to liver capsule distention. The nurse must recognize this as a
medical emergency to prevent further maternal and fetal morbidity.
3. A nurse is reviewing the electronic fetal monitor tracing of a client in active labor. The
nurse observes a sudden drop in the fetal heart rate (FHR) that is unrelated to contractions
and has a jagged ‘V’ shape. How should the nurse interpret this finding?
A. Umbilical cord compression (Variable decelerations).
B. Fetal head compression (Early decelerations).
C. Uteroplacental insufficiency (Late decelerations).
D. Fetal hypoxia (Accelerations).
, Answer: A
Rationale: Variable decelerations are characterized by a sudden, abrupt decrease in FHR
below the baseline with a quick return, often forming a V, U, or W shape. These are typically
caused by umbilical cord compression during labor. The nurse should change the client’s
position to relieve pressure on the cord and continue to monitor the FHR pattern closely.
4. Which medication should the nurse have readily available as an antidote for a client
receiving Magnesium Sulfate for seizure prophylaxis?
A. Calcium Gluconate
B. Naloxone
C. Terbutaline
D. Phytonadione
Answer: A
Rationale: Calcium gluconate is the specific antidote for magnesium sulfate toxicity. Signs
of toxicity include loss of deep tendon reflexes, respiratory depression, and cardiac arrest.
The nurse must keep this medication at the bedside whenever magnesium sulfate is being
administered intravenously.
5. A postpartum nurse is assessing a client 2 hours after a vaginal delivery. The nurse finds the
fundus is boggy and displaced to the right of the midline. Which action should the nurse take
first?
A. Massage the fundus until it is firm.
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 2) | Galen
College of Nursing
1. A nurse is monitoring a client in labor who is receiving an oxytocin infusion. The nurse
notes that the client is experiencing contractions every 90 seconds, lasting 70 to 80 seconds.
What is the priority nursing action?
A. Reposition the client to a side-lying position.
B. Administer oxygen via a non-rebreather mask.
C. Discontinue the oxytocin infusion immediately.
D. Increase the rate of the maintenance IV fluids.
Answer: C
Rationale: The client is exhibiting signs of uterine tachysystole, which is defined as more
than 5 contractions in a 10-minute period or contractions occurring less than 2 minutes
apart. The immediate priority is to stop the oxytocin to prevent uterine rupture and fetal
distress. Once the infusion is stopped, the nurse should then implement secondary
measures such as repositioning and oxygen therapy.
,2. A nurse is caring for a client at 34 weeks of gestation who has been diagnosed with severe
preeclampsia. Which of the following findings should the nurse report to the provider
immediately?
A. 1+ pitting edema in the lower extremities.
B. Blood pressure of 148/92 mmHg.
C. Epigastric pain or right upper quadrant pain.
D. Urinary output of 40 mL per hour.
Answer: C
Rationale: Epigastric pain is a warning sign of impending hepatic involvement or HELLP
syndrome, which is a severe complication of preeclampsia. This symptom often precedes a
seizure (eclampsia) due to liver capsule distention. The nurse must recognize this as a
medical emergency to prevent further maternal and fetal morbidity.
3. A nurse is reviewing the electronic fetal monitor tracing of a client in active labor. The
nurse observes a sudden drop in the fetal heart rate (FHR) that is unrelated to contractions
and has a jagged ‘V’ shape. How should the nurse interpret this finding?
A. Umbilical cord compression (Variable decelerations).
B. Fetal head compression (Early decelerations).
C. Uteroplacental insufficiency (Late decelerations).
D. Fetal hypoxia (Accelerations).
, Answer: A
Rationale: Variable decelerations are characterized by a sudden, abrupt decrease in FHR
below the baseline with a quick return, often forming a V, U, or W shape. These are typically
caused by umbilical cord compression during labor. The nurse should change the client’s
position to relieve pressure on the cord and continue to monitor the FHR pattern closely.
4. Which medication should the nurse have readily available as an antidote for a client
receiving Magnesium Sulfate for seizure prophylaxis?
A. Calcium Gluconate
B. Naloxone
C. Terbutaline
D. Phytonadione
Answer: A
Rationale: Calcium gluconate is the specific antidote for magnesium sulfate toxicity. Signs
of toxicity include loss of deep tendon reflexes, respiratory depression, and cardiac arrest.
The nurse must keep this medication at the bedside whenever magnesium sulfate is being
administered intravenously.
5. A postpartum nurse is assessing a client 2 hours after a vaginal delivery. The nurse finds the
fundus is boggy and displaced to the right of the midline. Which action should the nurse take
first?
A. Massage the fundus until it is firm.
