,NUR 231 Exam 2 | Concepts of Nursing: Childbearing & Child
Caring Families (2026) Q&A | Galen College
1. A nurse is assessing a client who is 24 hours postpartum. Which finding should
the nurse report to the provider immediately?
A) Fundus firm at the umbilicus
B) Lochia rubra with small clots
C) Saturation of one perineal pad in 15 minutes
D) Mild afterpains during breastfeeding
Correct Answer: Saturation of one perineal pad in 15 minutes
Rationale: Saturating a perineal pad in 15 minutes indicates excessive bleeding and
possible postpartum hemorrhage, requiring immediate intervention. A firm fundus
at the umbilicus, lochia rubra with small clots, and mild afterpains are expected
findings in the imme diate postpartum period.
2. Which hormone is responsible for milk production after delivery?
A) Oxytocin
B) Prolactin
C) Estrogen
D) Progesterone
Correct Answer: Prolactin
Rationale: Prolactin from the anterior pituitary stimulates milk production
(lactogenesis). Oxytocin causes milk ejection, while estrogen and progesterone
levels drop after placental delivery. Understanding hormonal roles is essential for
breastfeeding support.
3. A nurse is monitoring a client receiving oxytocin for labor induction. Which finding
requires immediate intervention?
A) Contractions every 3 minutes lasting 50 seconds
,B) Fetal heart rate baseline of 140 beats per minute
C) Uterine resting tone of 20 mm Hg between contractions
D) Contractions lasting 90 seconds with a resting tone of 30 mm Hg
Correct Answer: Contractions lasting 90 seconds with a resting tone of 30 mm Hg
Rationale: Contractions lasting longer than 90 seconds with elevated resting tone
indicate uterine hyperstimulation, which can impair placental perfusion and cause
fetal distress. The oxytocin should be stopped immediately. The other findings are
within normal limit s.
4. A client at 41 weeks' gestation is undergoing a non - stress test. Which finding
indicates a reactive result?
A) Two accelerations of 15 beats per minute lasting 15 seconds in 20 minutes
B) No accelerations in 40 minutes
C) Late decelerations with contractions
D) Variable decelerations with fetal movement
Correct Answer: Two accelerations of 15 beats per minute lasting 15 seconds in 20
minutes
Rationale: A reactive NST demonstrates adequate fetal oxygenation and well - being.
Two accelerations of 15 beats per minute lasting 15 seconds in 20 minutes meet the
criteria. Absence of accelerations requires further evaluation.
5. A nurse is caring for a client in the second stage of labor. Which finding indicates
imminent birth?
A) Cervical dilation of 8 cm
B) Bulging perineum and crowning
C) Contractions every 5 minutes
D) Bloody show
Correct Answer: Bulging perineum and crowning
, Rationale: Crowning occurs when the fetal head is visible at the vaginal opening,
indicating imminent birth. This is the classic sign that delivery is about to occur.
Dilatation of 8 cm is still in the first stage, and contractions every 5 minutes suggest
early acti ve labor.
6. Which medication is used to prevent seizures in a client with severe
preeclampsia?
A) Oxytocin
B) Magnesium sulfate
C) Terbutaline
D) Betamethasone
Correct Answer: Magnesium sulfate
Rationale: Magnesium sulfate is the standard medication for seizure prophylaxis in
severe preeclampsia. It works as a central nervous system depressant. The nurse
must monitor for magnesium toxicity, including loss of deep tendon reflexes and
respiratory depression.
7. A client receiving magnesium sulfate has a respiratory rate of 10 breaths per
minute and absent deep tendon reflexes. What is the nurse's priority action?
A) Continue the infusion as ordered
B) Increase the infusion rate
C) Stop the infusion and notify the provider
D) Administer oxytocin
Correct Answer: Stop the infusion and notify the provider
Rationale: Respiratory depression and absent deep tendon reflexes are signs of
magnesium toxicity. The nurse should stop the infusion immediately, notify the
provider, and prepare to administer calcium gluconate as an antidote. Continuing or
increasing the infusion could lead to respiratory arrest.
Caring Families (2026) Q&A | Galen College
1. A nurse is assessing a client who is 24 hours postpartum. Which finding should
the nurse report to the provider immediately?
A) Fundus firm at the umbilicus
B) Lochia rubra with small clots
C) Saturation of one perineal pad in 15 minutes
D) Mild afterpains during breastfeeding
Correct Answer: Saturation of one perineal pad in 15 minutes
Rationale: Saturating a perineal pad in 15 minutes indicates excessive bleeding and
possible postpartum hemorrhage, requiring immediate intervention. A firm fundus
at the umbilicus, lochia rubra with small clots, and mild afterpains are expected
findings in the imme diate postpartum period.
2. Which hormone is responsible for milk production after delivery?
A) Oxytocin
B) Prolactin
C) Estrogen
D) Progesterone
Correct Answer: Prolactin
Rationale: Prolactin from the anterior pituitary stimulates milk production
(lactogenesis). Oxytocin causes milk ejection, while estrogen and progesterone
levels drop after placental delivery. Understanding hormonal roles is essential for
breastfeeding support.
3. A nurse is monitoring a client receiving oxytocin for labor induction. Which finding
requires immediate intervention?
A) Contractions every 3 minutes lasting 50 seconds
,B) Fetal heart rate baseline of 140 beats per minute
C) Uterine resting tone of 20 mm Hg between contractions
D) Contractions lasting 90 seconds with a resting tone of 30 mm Hg
Correct Answer: Contractions lasting 90 seconds with a resting tone of 30 mm Hg
Rationale: Contractions lasting longer than 90 seconds with elevated resting tone
indicate uterine hyperstimulation, which can impair placental perfusion and cause
fetal distress. The oxytocin should be stopped immediately. The other findings are
within normal limit s.
4. A client at 41 weeks' gestation is undergoing a non - stress test. Which finding
indicates a reactive result?
A) Two accelerations of 15 beats per minute lasting 15 seconds in 20 minutes
B) No accelerations in 40 minutes
C) Late decelerations with contractions
D) Variable decelerations with fetal movement
Correct Answer: Two accelerations of 15 beats per minute lasting 15 seconds in 20
minutes
Rationale: A reactive NST demonstrates adequate fetal oxygenation and well - being.
Two accelerations of 15 beats per minute lasting 15 seconds in 20 minutes meet the
criteria. Absence of accelerations requires further evaluation.
5. A nurse is caring for a client in the second stage of labor. Which finding indicates
imminent birth?
A) Cervical dilation of 8 cm
B) Bulging perineum and crowning
C) Contractions every 5 minutes
D) Bloody show
Correct Answer: Bulging perineum and crowning
, Rationale: Crowning occurs when the fetal head is visible at the vaginal opening,
indicating imminent birth. This is the classic sign that delivery is about to occur.
Dilatation of 8 cm is still in the first stage, and contractions every 5 minutes suggest
early acti ve labor.
6. Which medication is used to prevent seizures in a client with severe
preeclampsia?
A) Oxytocin
B) Magnesium sulfate
C) Terbutaline
D) Betamethasone
Correct Answer: Magnesium sulfate
Rationale: Magnesium sulfate is the standard medication for seizure prophylaxis in
severe preeclampsia. It works as a central nervous system depressant. The nurse
must monitor for magnesium toxicity, including loss of deep tendon reflexes and
respiratory depression.
7. A client receiving magnesium sulfate has a respiratory rate of 10 breaths per
minute and absent deep tendon reflexes. What is the nurse's priority action?
A) Continue the infusion as ordered
B) Increase the infusion rate
C) Stop the infusion and notify the provider
D) Administer oxytocin
Correct Answer: Stop the infusion and notify the provider
Rationale: Respiratory depression and absent deep tendon reflexes are signs of
magnesium toxicity. The nurse should stop the infusion immediately, notify the
provider, and prepare to administer calcium gluconate as an antidote. Continuing or
increasing the infusion could lead to respiratory arrest.
