NUR 231 Exam 2 Actual Exam V2 | NUR 231 Childbearing & Child
Caring Family (NUR231 Exam 2) | Galen College of Nursing
1. A nurse is monitoring a client in active labor and notes a fetal heart rate (FHR) pattern
showing late decelerations. Which action should the nurse take first?
A. Reposition the client to a lateral position.
B. Administer oxygen via non-rebreather mask at 10 L/min.
C. Increase the rate of the intravenous maintenance fluids.
D. Document the findings and continue to observe.
Answer: A
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intrauterine resuscitation. The first step should be to reposition the patient to
the side to relieve pressure on the vena cava and improve blood flow. Subsequent steps
include increasing IV fluids, applying oxygen, and discontinuing oxytocin if applicable.
2. The nurse is caring for a client in the transition phase of labor. Which clinical manifestation
should the nurse expect to observe?
A. Cervical dilation of 3 to 5 cm.
B. Contractions occurring every 10 minutes.
C. Irritability, nausea, and a feeling of loss of control.
D. Increased social interaction and talkativeness.
Answer: C
Rationale: The transition phase is the final part of the first stage of labor, characterized by
cervical dilation of 8-10 cm. During this time, the client often experiences significant
physical distress, including nausea, vomiting, and extreme irritability. It is a critical period
where the nurse must provide intense emotional support and coaching.
3. A nurse is administering magnesium sulfate to a client with severe preeclampsia. Which
finding is most indicative of magnesium toxicity?
A. Blood pressure of 140/90 mmHg.
B. Presence of +2 deep tendon reflexes.
C. Respiratory rate of 10 breaths per minute.
D. Increased urinary output.
Answer: C
,Rationale: Magnesium sulfate is a central nervous system depressant used to prevent
seizures. Signs of toxicity include respiratory depression (less than 12 breaths per minute),
loss of deep tendon reflexes, and oliguria. If toxicity is suspected, the infusion must be
stopped immediately and calcium gluconate should be readily available as the antidote.
4. Following a vaginal delivery, a nurse assesses the fundus and finds it to be soft, boggy, and
displaced to the right. What is the priority nursing action?
A. Perform vigorous fundal massage.
B. Assist the client to the bathroom to void.
C. Notify the healthcare provider immediately.
D. Administer oxytocin as ordered.
Answer: B
Rationale: A fundus that is displaced to the right usually indicates a distended bladder,
which prevents the uterus from contracting effectively. Assisting the client to empty their
bladder will allow the uterus to return to the midline and firm up. While fundal massage is
important for a boggy uterus, addressing the bladder distension is the specific fix for
displacement.
5. A client requests an epidural for pain management. What is the most important nursing
intervention prior to the procedure?
A. Administer a 500-1000 mL bolus of IV lactated Ringer’s.
B. Verify the client has been NPO for at least 8 hours.
C. Perform a vaginal exam to confirm 8 cm dilation.
D. Assess the fetal heart rate for at least 60 minutes.
Answer: A
Rationale: Epidural anesthesia frequently causes maternal hypotension due to
sympathetic nervous system blockade. Administering a fluid bolus helps expand vascular
volume and minimize the risk of a sudden drop in blood pressure. Baseline vitals and FHR
should be monitored closely before, during, and after the procedure.
6. A nurse discovers a pulsating loop of the umbilical cord protruding from the vagina. Which
action should the nurse take immediately?
A. Attempt to push the cord back into the uterus.
B. Cover the cord with dry sterile gauze.
C. Place the client in the knee-chest or Trendelenburg position.
D. Begin preparation for a forceps-assisted delivery.
, Answer: C
Rationale: Cord prolapse is a medical emergency that threatens fetal oxygenation due to
compression of the umbilical cord. The nurse must use gravity to move the fetus off the
cord by placing the mother in a knee-chest or Trendelenburg position. Additionally, the
nurse should use a sterile gloved hand to apply upward pressure on the fetal presenting
part until a cesarean section can be performed.
7. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which
procedure is contraindicated?
A. Transabdominal ultrasound.
B. Electronic fetal monitoring.
C. Digital vaginal examination.
D. Checking maternal vital signs.
Answer: C
Rationale: Painless bright red bleeding is a hallmark sign of placenta previa. A digital
vaginal exam can puncture the placenta, leading to catastrophic maternal and fetal
hemorrhage. Diagnosis should be confirmed by ultrasound, and no vaginal examinations
should be performed until previa is ruled out.
8. A nurse is assessing a client for abruptio placentae. Which clinical findings should the nurse
expect? (Select all that apply)
A. Painless vaginal bleeding and soft abdomen.
B. Board-like, tender abdomen and dark red bleeding.
C. Both B and C are characteristic findings.
D. Increased uterine resting tone and fetal distress.
Answer: C
Rationale: Abruptio placentae involves the premature separation of the placenta from the
uterine wall, causing intense pain and uterine rigidity. The bleeding is often dark red and
may be concealed, leading to a board-like abdomen. This condition is a surgical emergency
due to the high risk of maternal DIC and fetal hypoxia.
9. The nurse notes moderate variability on a fetal heart rate strip. How should the nurse
interpret this finding?
A. Fetal hypoxia or CNS depression.
B. A normal, reassuring sign of fetal well-being.
C. The result of maternal narcotic administration.
Caring Family (NUR231 Exam 2) | Galen College of Nursing
1. A nurse is monitoring a client in active labor and notes a fetal heart rate (FHR) pattern
showing late decelerations. Which action should the nurse take first?
A. Reposition the client to a lateral position.
B. Administer oxygen via non-rebreather mask at 10 L/min.
C. Increase the rate of the intravenous maintenance fluids.
D. Document the findings and continue to observe.
Answer: A
Rationale: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intrauterine resuscitation. The first step should be to reposition the patient to
the side to relieve pressure on the vena cava and improve blood flow. Subsequent steps
include increasing IV fluids, applying oxygen, and discontinuing oxytocin if applicable.
2. The nurse is caring for a client in the transition phase of labor. Which clinical manifestation
should the nurse expect to observe?
A. Cervical dilation of 3 to 5 cm.
B. Contractions occurring every 10 minutes.
C. Irritability, nausea, and a feeling of loss of control.
D. Increased social interaction and talkativeness.
Answer: C
Rationale: The transition phase is the final part of the first stage of labor, characterized by
cervical dilation of 8-10 cm. During this time, the client often experiences significant
physical distress, including nausea, vomiting, and extreme irritability. It is a critical period
where the nurse must provide intense emotional support and coaching.
3. A nurse is administering magnesium sulfate to a client with severe preeclampsia. Which
finding is most indicative of magnesium toxicity?
A. Blood pressure of 140/90 mmHg.
B. Presence of +2 deep tendon reflexes.
C. Respiratory rate of 10 breaths per minute.
D. Increased urinary output.
Answer: C
,Rationale: Magnesium sulfate is a central nervous system depressant used to prevent
seizures. Signs of toxicity include respiratory depression (less than 12 breaths per minute),
loss of deep tendon reflexes, and oliguria. If toxicity is suspected, the infusion must be
stopped immediately and calcium gluconate should be readily available as the antidote.
4. Following a vaginal delivery, a nurse assesses the fundus and finds it to be soft, boggy, and
displaced to the right. What is the priority nursing action?
A. Perform vigorous fundal massage.
B. Assist the client to the bathroom to void.
C. Notify the healthcare provider immediately.
D. Administer oxytocin as ordered.
Answer: B
Rationale: A fundus that is displaced to the right usually indicates a distended bladder,
which prevents the uterus from contracting effectively. Assisting the client to empty their
bladder will allow the uterus to return to the midline and firm up. While fundal massage is
important for a boggy uterus, addressing the bladder distension is the specific fix for
displacement.
5. A client requests an epidural for pain management. What is the most important nursing
intervention prior to the procedure?
A. Administer a 500-1000 mL bolus of IV lactated Ringer’s.
B. Verify the client has been NPO for at least 8 hours.
C. Perform a vaginal exam to confirm 8 cm dilation.
D. Assess the fetal heart rate for at least 60 minutes.
Answer: A
Rationale: Epidural anesthesia frequently causes maternal hypotension due to
sympathetic nervous system blockade. Administering a fluid bolus helps expand vascular
volume and minimize the risk of a sudden drop in blood pressure. Baseline vitals and FHR
should be monitored closely before, during, and after the procedure.
6. A nurse discovers a pulsating loop of the umbilical cord protruding from the vagina. Which
action should the nurse take immediately?
A. Attempt to push the cord back into the uterus.
B. Cover the cord with dry sterile gauze.
C. Place the client in the knee-chest or Trendelenburg position.
D. Begin preparation for a forceps-assisted delivery.
, Answer: C
Rationale: Cord prolapse is a medical emergency that threatens fetal oxygenation due to
compression of the umbilical cord. The nurse must use gravity to move the fetus off the
cord by placing the mother in a knee-chest or Trendelenburg position. Additionally, the
nurse should use a sterile gloved hand to apply upward pressure on the fetal presenting
part until a cesarean section can be performed.
7. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which
procedure is contraindicated?
A. Transabdominal ultrasound.
B. Electronic fetal monitoring.
C. Digital vaginal examination.
D. Checking maternal vital signs.
Answer: C
Rationale: Painless bright red bleeding is a hallmark sign of placenta previa. A digital
vaginal exam can puncture the placenta, leading to catastrophic maternal and fetal
hemorrhage. Diagnosis should be confirmed by ultrasound, and no vaginal examinations
should be performed until previa is ruled out.
8. A nurse is assessing a client for abruptio placentae. Which clinical findings should the nurse
expect? (Select all that apply)
A. Painless vaginal bleeding and soft abdomen.
B. Board-like, tender abdomen and dark red bleeding.
C. Both B and C are characteristic findings.
D. Increased uterine resting tone and fetal distress.
Answer: C
Rationale: Abruptio placentae involves the premature separation of the placenta from the
uterine wall, causing intense pain and uterine rigidity. The bleeding is often dark red and
may be concealed, leading to a board-like abdomen. This condition is a surgical emergency
due to the high risk of maternal DIC and fetal hypoxia.
9. The nurse notes moderate variability on a fetal heart rate strip. How should the nurse
interpret this finding?
A. Fetal hypoxia or CNS depression.
B. A normal, reassuring sign of fetal well-being.
C. The result of maternal narcotic administration.
