NUR 230 Exam 2 V2 | NUR 230 The
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 2) | Galen
College of Nursing
1. A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate. Which of the following findings should the nurse identify as the priority
to report to the provider?
A. Respiratory rate of 10/min
B. Urinary output of 40 mL/hr
C. Generalized feeling of warmth
D. Deep tendon reflexes of 2+
Answer: A
Rationale: Magnesium sulfate toxicity is a critical concern that can lead to respiratory
depression and cardiac arrest. A respiratory rate of less than 12/min is a primary indicator
of toxicity and requires immediate cessation of the infusion. The nurse must also notify the
provider and prepare to administer calcium gluconate as an antidote.
2. A nurse is assessing a client in the active phase of labor. The electronic fetal monitor shows
late decelerations. Which of the following actions should the nurse take first?
A. Administer oxygen via nonrebreather mask
,B. Increase the rate of IV fluid infusion
C. Perform a vaginal examination
D. Assist the client into a side-lying position
Answer: D
Rationale: Late decelerations are caused by uteroplacental insufficiency and indicate fetal
distress. Repositioning the mother to a side-lying position is the first action to improve
blood flow to the placenta and fetus. Following this, the nurse should increase IV fluids and
provide oxygen to further optimize fetal oxygenation.
3. A nurse is caring for a newborn immediately following birth. Which of the following actions
is the priority?
A. Administer Vitamin K intramuscularly
B. Apply erythromycin ophthalmic ointment
C. Dry the newborn and provide skin-to-skin contact
D. Obtain the newborn’s weight and length
Answer: C
Rationale: Drying the newborn is essential to prevent heat loss through evaporation and
stabilize the infant’s temperature. Maintaining thermoregulation is a physiological priority
to prevent cold stress and metabolic acidosis. Skin-to-skin contact also promotes bonding
and initial breastfeeding success.
, 4. A client at 38 weeks of gestation reports painless, bright red vaginal bleeding. Which of the
following conditions should the nurse suspect?
A. Abruptio placentae
B. Preterm labor
C. Ruptured uterus
D. Placenta previa
Answer: D
Rationale: Placenta previa is characterized by the presence of painless, bright red vaginal
bleeding during the second or third trimester. This occurs when the placenta partially or
totally covers the cervix. In contrast, abruptio placentae typically presents with painful,
dark red bleeding and board-like abdominal rigidity.
5. A nurse is assessing a client who is 2 hours postpartum. The nurse notes the fundus is
boggy and displaced to the right. Which of the following actions should the nurse take?
A. Assist the client to empty her bladder
B. Increase the oxytocin infusion rate
C. Massage the fundus immediately
D. Notify the healthcare provider
Answer: A
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 2) | Galen
College of Nursing
1. A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for
magnesium sulfate. Which of the following findings should the nurse identify as the priority
to report to the provider?
A. Respiratory rate of 10/min
B. Urinary output of 40 mL/hr
C. Generalized feeling of warmth
D. Deep tendon reflexes of 2+
Answer: A
Rationale: Magnesium sulfate toxicity is a critical concern that can lead to respiratory
depression and cardiac arrest. A respiratory rate of less than 12/min is a primary indicator
of toxicity and requires immediate cessation of the infusion. The nurse must also notify the
provider and prepare to administer calcium gluconate as an antidote.
2. A nurse is assessing a client in the active phase of labor. The electronic fetal monitor shows
late decelerations. Which of the following actions should the nurse take first?
A. Administer oxygen via nonrebreather mask
,B. Increase the rate of IV fluid infusion
C. Perform a vaginal examination
D. Assist the client into a side-lying position
Answer: D
Rationale: Late decelerations are caused by uteroplacental insufficiency and indicate fetal
distress. Repositioning the mother to a side-lying position is the first action to improve
blood flow to the placenta and fetus. Following this, the nurse should increase IV fluids and
provide oxygen to further optimize fetal oxygenation.
3. A nurse is caring for a newborn immediately following birth. Which of the following actions
is the priority?
A. Administer Vitamin K intramuscularly
B. Apply erythromycin ophthalmic ointment
C. Dry the newborn and provide skin-to-skin contact
D. Obtain the newborn’s weight and length
Answer: C
Rationale: Drying the newborn is essential to prevent heat loss through evaporation and
stabilize the infant’s temperature. Maintaining thermoregulation is a physiological priority
to prevent cold stress and metabolic acidosis. Skin-to-skin contact also promotes bonding
and initial breastfeeding success.
, 4. A client at 38 weeks of gestation reports painless, bright red vaginal bleeding. Which of the
following conditions should the nurse suspect?
A. Abruptio placentae
B. Preterm labor
C. Ruptured uterus
D. Placenta previa
Answer: D
Rationale: Placenta previa is characterized by the presence of painless, bright red vaginal
bleeding during the second or third trimester. This occurs when the placenta partially or
totally covers the cervix. In contrast, abruptio placentae typically presents with painful,
dark red bleeding and board-like abdominal rigidity.
5. A nurse is assessing a client who is 2 hours postpartum. The nurse notes the fundus is
boggy and displaced to the right. Which of the following actions should the nurse take?
A. Assist the client to empty her bladder
B. Increase the oxytocin infusion rate
C. Massage the fundus immediately
D. Notify the healthcare provider
Answer: A
