NUR 231 Exam 3: Childbearing & Child Caring Family 2026 Galen
1. A nurse is assessing a client in the active phase of labor. The client’s cervix is
dilated to 7 cm and contractions are occurring every 3 minutes. Which of the
following is the priority nursing action?
A. Encourage the client to use patterned-paced breathing techniques
B. Prepare the client for an immediate cesarean section
C. Administer an opioid analgesic for pain relief
D. Assess the fetal heart rate and contraction pattern
Answer: D
Rationale: In the active phase of labor, continuous monitoring of the fetal heart rate and
contraction pattern is essential to ensure fetal well-being and progress of labor.
2. A nurse is caring for a client who is receiving oxytocin for labor induction. The
nurse notes late decelerations on the fetal heart rate monitor. Which of the
following actions should the nurse take first?
A. Turn the client onto her left side
B. Increase the rate of oxytocin infusion
C. Perform a vaginal exam to check for cord prolapse
D. Prepare for an amnioinfusion
Answer: A
Rationale: Late decelerations indicate uteroplacental insufficiency. The first action is to
reposition the client to the left side to improve blood flow to the placenta.
,3. A newborn has an APGAR score of 9 at 1 minute and 9 at 5 minutes. The
nurse should interpret these scores as which of the following?
A. The newborn is experiencing severe distress
B. The newborn is having difficulty transitioning to extrauterine life
C. The newborn requires immediate resuscitation
D. The newborn is in stable condition
Answer: D
Rationale: An APGAR score of 7 to 10 is considered normal and indicates that the newborn
is in stable condition and adjusting well to extrauterine life.
4. A nurse is monitoring a client in the fourth stage of labor. The nurse finds the
client’s fundus is boggy and displaced to the right. Which of the following is the
most likely cause?
A. Normal physiological change
B. Retained placental fragments
C. Endometritis
D. Uterine atony due to a full bladder
Answer: D
Rationale: A boggy fundus displaced to the right usually indicates a full bladder, which
prevents the uterus from contracting effectively and increases the risk of hemorrhage.
5. Which of the following is a characteristic of lochia rubra?
A. Yellowish-white discharge lasting 10 to 14 days
B. Pinkish-brown discharge lasting 4 to 10 days
C. Clear, watery discharge containing mostly mucus
D. Bright red discharge lasting 1 to 3 days postpartum
Answer: D
Rationale: Lochia rubra is the first stage of postpartum discharge, consisting of blood and
decidual debris, appearing bright red for the first 1 to 3 days.
, 6. A client is receiving magnesium sulfate for pre-eclampsia. Which of the
following findings should the nurse report to the provider as a sign of toxicity?
A. Deep tendon reflexes 2+
B. Respiratory rate of 10 breaths/min
C. Urine output of 40 mL/hr
D. A sense of warmth and flushing
Answer: B
Rationale: Signs of magnesium sulfate toxicity include a respiratory rate less than 12
breaths/min, loss of deep tendon reflexes, and decreased urine output.
7. A nurse is teaching a new mother about breastfeeding. Which of the
following statements by the mother indicates an understanding of the teaching?
A. ‘My baby’s mouth should cover most of the areola, not just the nipple.’
B. ‘I should feed my baby on a strict schedule every 4 hours.’
C. ‘I will give my baby water between feedings if it is hot outside.’
D. ‘I should use a nipple shield for every feeding to prevent soreness.’
Answer: A
Rationale: A proper latch involves the infant taking a large portion of the areola into the
mouth, which ensures effective milk transfer and prevents nipple trauma.
8. A nurse is assessing a newborn with neonatal jaundice receiving
phototherapy. Which of the following nursing actions is essential?
A. Apply lotion to the baby’s skin to prevent drying
B. Keep the infant’s eyes covered with opaque shields
C. Limit fluid intake to prevent overhydration
D. Discontinue therapy during all feedings
Answer: B
Rationale: Eye shields are necessary during phototherapy to prevent damage to the
newborn’s retina from the high-intensity light.
1. A nurse is assessing a client in the active phase of labor. The client’s cervix is
dilated to 7 cm and contractions are occurring every 3 minutes. Which of the
following is the priority nursing action?
A. Encourage the client to use patterned-paced breathing techniques
B. Prepare the client for an immediate cesarean section
C. Administer an opioid analgesic for pain relief
D. Assess the fetal heart rate and contraction pattern
Answer: D
Rationale: In the active phase of labor, continuous monitoring of the fetal heart rate and
contraction pattern is essential to ensure fetal well-being and progress of labor.
2. A nurse is caring for a client who is receiving oxytocin for labor induction. The
nurse notes late decelerations on the fetal heart rate monitor. Which of the
following actions should the nurse take first?
A. Turn the client onto her left side
B. Increase the rate of oxytocin infusion
C. Perform a vaginal exam to check for cord prolapse
D. Prepare for an amnioinfusion
Answer: A
Rationale: Late decelerations indicate uteroplacental insufficiency. The first action is to
reposition the client to the left side to improve blood flow to the placenta.
,3. A newborn has an APGAR score of 9 at 1 minute and 9 at 5 minutes. The
nurse should interpret these scores as which of the following?
A. The newborn is experiencing severe distress
B. The newborn is having difficulty transitioning to extrauterine life
C. The newborn requires immediate resuscitation
D. The newborn is in stable condition
Answer: D
Rationale: An APGAR score of 7 to 10 is considered normal and indicates that the newborn
is in stable condition and adjusting well to extrauterine life.
4. A nurse is monitoring a client in the fourth stage of labor. The nurse finds the
client’s fundus is boggy and displaced to the right. Which of the following is the
most likely cause?
A. Normal physiological change
B. Retained placental fragments
C. Endometritis
D. Uterine atony due to a full bladder
Answer: D
Rationale: A boggy fundus displaced to the right usually indicates a full bladder, which
prevents the uterus from contracting effectively and increases the risk of hemorrhage.
5. Which of the following is a characteristic of lochia rubra?
A. Yellowish-white discharge lasting 10 to 14 days
B. Pinkish-brown discharge lasting 4 to 10 days
C. Clear, watery discharge containing mostly mucus
D. Bright red discharge lasting 1 to 3 days postpartum
Answer: D
Rationale: Lochia rubra is the first stage of postpartum discharge, consisting of blood and
decidual debris, appearing bright red for the first 1 to 3 days.
, 6. A client is receiving magnesium sulfate for pre-eclampsia. Which of the
following findings should the nurse report to the provider as a sign of toxicity?
A. Deep tendon reflexes 2+
B. Respiratory rate of 10 breaths/min
C. Urine output of 40 mL/hr
D. A sense of warmth and flushing
Answer: B
Rationale: Signs of magnesium sulfate toxicity include a respiratory rate less than 12
breaths/min, loss of deep tendon reflexes, and decreased urine output.
7. A nurse is teaching a new mother about breastfeeding. Which of the
following statements by the mother indicates an understanding of the teaching?
A. ‘My baby’s mouth should cover most of the areola, not just the nipple.’
B. ‘I should feed my baby on a strict schedule every 4 hours.’
C. ‘I will give my baby water between feedings if it is hot outside.’
D. ‘I should use a nipple shield for every feeding to prevent soreness.’
Answer: A
Rationale: A proper latch involves the infant taking a large portion of the areola into the
mouth, which ensures effective milk transfer and prevents nipple trauma.
8. A nurse is assessing a newborn with neonatal jaundice receiving
phototherapy. Which of the following nursing actions is essential?
A. Apply lotion to the baby’s skin to prevent drying
B. Keep the infant’s eyes covered with opaque shields
C. Limit fluid intake to prevent overhydration
D. Discontinue therapy during all feedings
Answer: B
Rationale: Eye shields are necessary during phototherapy to prevent damage to the
newborn’s retina from the high-intensity light.
