NUR 231 Exam 3: Childbearing & Child Caring Family 2026 Galen
1. A nurse is assessing a postpartum client 2 hours after delivery and finds the
fundus boggy and displaced to the right. What is the priority nursing action?
A. Encourage the client to void
B. Massage the fundus until firm
C. Administer oxytocin as ordered
D. Call the healthcare provider
Answer: A
Rationale: A displaced fundus to the right usually indicates a distended bladder, which can
prevent the uterus from contracting, leading to hemorrhage. Voiding is the priority to allow
the fundus to return to the midline.
2. Which medication is considered the antidote for Magnesium Sulfate toxicity
in a client with preeclampsia?
A. Naloxone
B. Terbutaline
C. Hydralazine
D. Calcium Gluconate
Answer: D
Rationale: Calcium Gluconate is the specific antidote used to reverse the effects of
magnesium sulfate toxicity, such as respiratory depression and loss of deep tendon
reflexes.
,3. A newborn’s APGAR score at 1 minute shows a heart rate of 110,
slow/irregular respiratory effort, some flexion of extremities, grimace during
suctioning, and a pink body with blue extremities. What is the score?
A. 6
B. 5
C. 7
D. 8
Answer: A
Rationale: Heart rate >100 (2), Slow/irregular respiratory (1), Flexion (1), Grimace (1),
Acrocyanosis (1). Total = 6.
4. Which of the following findings in a newborn should the nurse report to the
provider immediately?
A. Vernix caseosa in skin folds
B. Generalized petechiae
C. Milia on the nose
D. Acrocyanosis
Answer: B
Rationale: Generalized petechiae can indicate a clotting factor deficiency or infection and
require immediate investigation, whereas the other options are normal newborn findings.
5. When evaluating a fetal heart rate (FHR) tracing, the nurse notes early
decelerations. What is the most likely cause?
A. Fetal head compression
B. Umbilical cord compression
C. Uteroplacental insufficiency
D. Fetal hypoxia
Answer: A
, Rationale: Early decelerations are a result of head compression during contractions and
are considered a benign finding.
6. A nurse is monitoring a client on Magnesium Sulfate. Which assessment
finding indicates toxicity?
A. Deep tendon reflexes 2+
B. Urinary output of 40 mL/hr
C. Blood pressure 140/90 mmHg
D. Respiratory rate of 10/min
Answer: D
Rationale: Signs of magnesium toxicity include a respiratory rate less than 12/min, loss of
deep tendon reflexes, and decreased urinary output.
7. A client is in the transition phase of the first stage of labor. Which clinical
manifestation should the nurse expect?
A. Cervical dilation of 3 cm
B. Increased appetite and energy
C. Irritability and a feeling of loss of control
D. Contractions every 10 minutes
Answer: C
Rationale: The transition phase (8-10 cm) is characterized by intense contractions,
irritability, nausea, and a feeling of being overwhelmed.
8. Which of the following is a priority intervention for a newborn receiving
phototherapy for jaundice?
A. Applying lotion to the skin to prevent dryness
B. Checking the temperature every 8 hours
C. Limiting fluid intake to prevent diarrhea
D. Keeping the eyes covered with an opaque mask
Answer: D
1. A nurse is assessing a postpartum client 2 hours after delivery and finds the
fundus boggy and displaced to the right. What is the priority nursing action?
A. Encourage the client to void
B. Massage the fundus until firm
C. Administer oxytocin as ordered
D. Call the healthcare provider
Answer: A
Rationale: A displaced fundus to the right usually indicates a distended bladder, which can
prevent the uterus from contracting, leading to hemorrhage. Voiding is the priority to allow
the fundus to return to the midline.
2. Which medication is considered the antidote for Magnesium Sulfate toxicity
in a client with preeclampsia?
A. Naloxone
B. Terbutaline
C. Hydralazine
D. Calcium Gluconate
Answer: D
Rationale: Calcium Gluconate is the specific antidote used to reverse the effects of
magnesium sulfate toxicity, such as respiratory depression and loss of deep tendon
reflexes.
,3. A newborn’s APGAR score at 1 minute shows a heart rate of 110,
slow/irregular respiratory effort, some flexion of extremities, grimace during
suctioning, and a pink body with blue extremities. What is the score?
A. 6
B. 5
C. 7
D. 8
Answer: A
Rationale: Heart rate >100 (2), Slow/irregular respiratory (1), Flexion (1), Grimace (1),
Acrocyanosis (1). Total = 6.
4. Which of the following findings in a newborn should the nurse report to the
provider immediately?
A. Vernix caseosa in skin folds
B. Generalized petechiae
C. Milia on the nose
D. Acrocyanosis
Answer: B
Rationale: Generalized petechiae can indicate a clotting factor deficiency or infection and
require immediate investigation, whereas the other options are normal newborn findings.
5. When evaluating a fetal heart rate (FHR) tracing, the nurse notes early
decelerations. What is the most likely cause?
A. Fetal head compression
B. Umbilical cord compression
C. Uteroplacental insufficiency
D. Fetal hypoxia
Answer: A
, Rationale: Early decelerations are a result of head compression during contractions and
are considered a benign finding.
6. A nurse is monitoring a client on Magnesium Sulfate. Which assessment
finding indicates toxicity?
A. Deep tendon reflexes 2+
B. Urinary output of 40 mL/hr
C. Blood pressure 140/90 mmHg
D. Respiratory rate of 10/min
Answer: D
Rationale: Signs of magnesium toxicity include a respiratory rate less than 12/min, loss of
deep tendon reflexes, and decreased urinary output.
7. A client is in the transition phase of the first stage of labor. Which clinical
manifestation should the nurse expect?
A. Cervical dilation of 3 cm
B. Increased appetite and energy
C. Irritability and a feeling of loss of control
D. Contractions every 10 minutes
Answer: C
Rationale: The transition phase (8-10 cm) is characterized by intense contractions,
irritability, nausea, and a feeling of being overwhelmed.
8. Which of the following is a priority intervention for a newborn receiving
phototherapy for jaundice?
A. Applying lotion to the skin to prevent dryness
B. Checking the temperature every 8 hours
C. Limiting fluid intake to prevent diarrhea
D. Keeping the eyes covered with an opaque mask
Answer: D
