NUR 230 Exam 2 V3 | 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 in the first stage of labor and observes late decelerations on
the fetal heart rate monitor. Which of the following actions should the nurse take first?
A. Administer oxygen at 8 to 10 L/min via nonrebreather face mask.
B. Increase the rate of the maintenance intravenous infusion.
C. Assist the client into a lateral position.
D. Perform a vaginal examination to check for cord prolapse.
Answer: C
Rationale: Late decelerations are indicative of uteroplacental insufficiency, which can
compromise fetal oxygenation. Repositioning the client to a side-lying position is the first
action to improve blood flow to the placenta. After repositioning, the nurse should then
consider oxygen administration and increasing IV fluids to further support maternal
circulation.
2. 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. Generalized petechiae over the trunk.
C. Milia across the bridge of the nose.
D. Transient tachypnea with a respiratory rate of 50/min.
Answer: B
Rationale: Generalized petechiae can indicate a clotting factor deficiency or infection and
require immediate medical evaluation. Acrocyanosis is a normal finding in the first 24 to 48
hours of life due to poor peripheral circulation. Milia are common sebaceous gland
secretions that resolve spontaneously without intervention.
3. A nurse is providing teaching to a client who is at 12 weeks of gestation and has a new
prescription for an iron supplement. Which of the following instructions should the nurse
include?
A. Take the medication with a glass of milk.
B. Take the supplement immediately before going to bed.
C. Expect stools to become dark green or black in color.
D. Avoid drinking orange juice while taking this medication.
Answer: C
Rationale: Iron supplements commonly cause stools to turn a dark green or black color,
which is a harmless side effect. Taking iron with vitamin C, such as orange juice, actually
, enhances its absorption. Conversely, milk and calcium can inhibit the absorption of iron
and should be avoided at the time of administration.
4. A nurse is caring for a client who is at 34 weeks of gestation and has a diagnosis of severe
preeclampsia. Which of the following medications should the nurse expect to administer?
A. Nifedipine
B. Oxytocin
C. Magnesium sulfate
D. Terbutaline
Answer: C
Rationale: Magnesium sulfate is the drug of choice for preventing seizures in clients with
severe preeclampsia. The nurse must monitor for signs of toxicity, such as loss of deep
tendon reflexes and respiratory depression. While nifedipine may be used for blood
pressure control, magnesium sulfate is specific to seizure prophylaxis in this context.
5. A nurse is assessing a client who is 2 hours postpartum. The nurse notes that the fundus is
boggy and displaced to the right. Which of the following actions should the nurse take?
A. Administer oxytocin 10 units IM.
B. Assist the client to the bathroom to void.
C. Perform vigorous fundal massage.
D. Insert an indwelling urinary catheter.
Childbearing / Child Caring Family | Q&A
with Rationale (NUR230 Exam 2) | Galen
College of Nursing
1. A nurse is caring for a client in the first stage of labor and observes late decelerations on
the fetal heart rate monitor. Which of the following actions should the nurse take first?
A. Administer oxygen at 8 to 10 L/min via nonrebreather face mask.
B. Increase the rate of the maintenance intravenous infusion.
C. Assist the client into a lateral position.
D. Perform a vaginal examination to check for cord prolapse.
Answer: C
Rationale: Late decelerations are indicative of uteroplacental insufficiency, which can
compromise fetal oxygenation. Repositioning the client to a side-lying position is the first
action to improve blood flow to the placenta. After repositioning, the nurse should then
consider oxygen administration and increasing IV fluids to further support maternal
circulation.
2. 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. Generalized petechiae over the trunk.
C. Milia across the bridge of the nose.
D. Transient tachypnea with a respiratory rate of 50/min.
Answer: B
Rationale: Generalized petechiae can indicate a clotting factor deficiency or infection and
require immediate medical evaluation. Acrocyanosis is a normal finding in the first 24 to 48
hours of life due to poor peripheral circulation. Milia are common sebaceous gland
secretions that resolve spontaneously without intervention.
3. A nurse is providing teaching to a client who is at 12 weeks of gestation and has a new
prescription for an iron supplement. Which of the following instructions should the nurse
include?
A. Take the medication with a glass of milk.
B. Take the supplement immediately before going to bed.
C. Expect stools to become dark green or black in color.
D. Avoid drinking orange juice while taking this medication.
Answer: C
Rationale: Iron supplements commonly cause stools to turn a dark green or black color,
which is a harmless side effect. Taking iron with vitamin C, such as orange juice, actually
, enhances its absorption. Conversely, milk and calcium can inhibit the absorption of iron
and should be avoided at the time of administration.
4. A nurse is caring for a client who is at 34 weeks of gestation and has a diagnosis of severe
preeclampsia. Which of the following medications should the nurse expect to administer?
A. Nifedipine
B. Oxytocin
C. Magnesium sulfate
D. Terbutaline
Answer: C
Rationale: Magnesium sulfate is the drug of choice for preventing seizures in clients with
severe preeclampsia. The nurse must monitor for signs of toxicity, such as loss of deep
tendon reflexes and respiratory depression. While nifedipine may be used for blood
pressure control, magnesium sulfate is specific to seizure prophylaxis in this context.
5. A nurse is assessing a client who is 2 hours postpartum. The nurse notes that the fundus is
boggy and displaced to the right. Which of the following actions should the nurse take?
A. Administer oxytocin 10 units IM.
B. Assist the client to the bathroom to void.
C. Perform vigorous fundal massage.
D. Insert an indwelling urinary catheter.
