NUR254 | NUR254 Concepts of Nursing; The
Childbearing and Child Caring Families Exam 2
Version 1 Questions with Correct Answers and
Expert Explanation for Each Question
1. A pregnant client at 26 weeks gestation is undergoing a 1-hour oral glucose
tolerance test (OGTT). Which result would require the nurse to schedule the client for
a 3-hour glucose tolerance test?
A. 80 mg/dL
B. 110 mg/dL
C. 145 mg/dL
D. 130 mg/dL
Correct Answer: C
Expert Explanation: The clinical focus of this question is gestational diabetes
screening protocols. A blood glucose level above 140 mg/dL after a 1-hour test
indicates a positive screen requiring further diagnostic testing. Options A, B, and D
fall within the normal range for the initial 1-hour screening process. The 3-hour test
is the definitive diagnostic tool used to confirm gestational diabetes mellitus. Early
detection allows for nutritional and medical interventions to prevent complications
like macrosomia.
,2. The nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding should the nurse report immediately as a sign of toxicity?
A. Presence of deep tendon reflexes (+2)
B. Blood pressure of 140/90 mmHg
C. Respiratory rate of 10 breaths per minute
D. Urinary output of 40 mL per hour
Correct Answer: C
Expert Explanation: The primary safety concern when administering magnesium
sulfate is monitoring for central nervous system depression. A respiratory rate
below 12 breaths per minute is a classic indicator of magnesium toxicity that
requires immediate intervention. Normal urinary output and the presence of deep
tendon reflexes suggest the medication is at a therapeutic level. The nurse must be
prepared to administer calcium gluconate if toxic signs occur. Vigilant monitoring
prevents respiratory arrest and ensures maternal safety during hypertensive
management.
3. A nurse is reviewing a fetal heart rate (FHR) tracing and observes late decelerations.
Which action should the nurse take first?
A. Reposition the client to a side-lying position
B. Increase the oxytocin infusion rate
,C. Perform a vaginal examination
D. Administer a Bolus of 500 mL dextrose in water
Correct Answer: A
Expert Explanation: Late decelerations are indicative of uteroplacental
insufficiency and require immediate nursing action to improve fetal oxygenation.
Repositioning the mother to her side relieves pressure on the vena cava and
enhances blood flow to the placenta. Increasing oxytocin would worsen fetal
distress by causing more frequent contractions. Intravenous fluids should be non-
dextrose lactated Ringer’s if a bolus is indicated for resuscitation. Prompt
intervention is critical to prevent fetal hypoxia and metabolic acidosis.
4. A nurse is assessing a pregnant client for signs of placental abruption. Which finding
is most characteristic of this condition?
A. Painless, bright red vaginal bleeding
B. Soft, non-tender uterus
C. Intermittent contractions with normal FHR
D. Abdominal pain with a board-like abdomen
Correct Answer: D
, Expert Explanation: Placental abruption involves the premature separation of the
placenta from the uterine wall, often causing severe pain. A board-like, rigid
abdomen is a hallmark sign caused by concealed or overt hemorrhage into the
uterine muscle. Painless bleeding is more typical of placenta previa rather than an
abruption. Distinguishing between these two conditions is vital for determining the
urgency of delivery. The nurse must prioritize monitoring for signs of maternal
shock and fetal distress in these cases.
5. A client at 30 weeks gestation is admitted for preterm labor. The physician orders
Betamethasone. What is the primary purpose of this medication?
A. To stop uterine contractions
B. To prevent maternal infection
C. To increase maternal blood pressure
D. To promote fetal lung maturity
Correct Answer: D
Expert Explanation: Betamethasone is a corticosteroid administered to mothers in
preterm labor to enhance fetal lung development. It stimulates the production of
surfactant, which reduces the risk of respiratory distress syndrome in the neonate.
This medication does not have tocolytic properties and will not stop labor
contractions. It is typically given in two doses 24 hours apart for maximum
Childbearing and Child Caring Families Exam 2
Version 1 Questions with Correct Answers and
Expert Explanation for Each Question
1. A pregnant client at 26 weeks gestation is undergoing a 1-hour oral glucose
tolerance test (OGTT). Which result would require the nurse to schedule the client for
a 3-hour glucose tolerance test?
A. 80 mg/dL
B. 110 mg/dL
C. 145 mg/dL
D. 130 mg/dL
Correct Answer: C
Expert Explanation: The clinical focus of this question is gestational diabetes
screening protocols. A blood glucose level above 140 mg/dL after a 1-hour test
indicates a positive screen requiring further diagnostic testing. Options A, B, and D
fall within the normal range for the initial 1-hour screening process. The 3-hour test
is the definitive diagnostic tool used to confirm gestational diabetes mellitus. Early
detection allows for nutritional and medical interventions to prevent complications
like macrosomia.
,2. The nurse is caring for a client receiving Magnesium Sulfate for preeclampsia. Which
assessment finding should the nurse report immediately as a sign of toxicity?
A. Presence of deep tendon reflexes (+2)
B. Blood pressure of 140/90 mmHg
C. Respiratory rate of 10 breaths per minute
D. Urinary output of 40 mL per hour
Correct Answer: C
Expert Explanation: The primary safety concern when administering magnesium
sulfate is monitoring for central nervous system depression. A respiratory rate
below 12 breaths per minute is a classic indicator of magnesium toxicity that
requires immediate intervention. Normal urinary output and the presence of deep
tendon reflexes suggest the medication is at a therapeutic level. The nurse must be
prepared to administer calcium gluconate if toxic signs occur. Vigilant monitoring
prevents respiratory arrest and ensures maternal safety during hypertensive
management.
3. A nurse is reviewing a fetal heart rate (FHR) tracing and observes late decelerations.
Which action should the nurse take first?
A. Reposition the client to a side-lying position
B. Increase the oxytocin infusion rate
,C. Perform a vaginal examination
D. Administer a Bolus of 500 mL dextrose in water
Correct Answer: A
Expert Explanation: Late decelerations are indicative of uteroplacental
insufficiency and require immediate nursing action to improve fetal oxygenation.
Repositioning the mother to her side relieves pressure on the vena cava and
enhances blood flow to the placenta. Increasing oxytocin would worsen fetal
distress by causing more frequent contractions. Intravenous fluids should be non-
dextrose lactated Ringer’s if a bolus is indicated for resuscitation. Prompt
intervention is critical to prevent fetal hypoxia and metabolic acidosis.
4. A nurse is assessing a pregnant client for signs of placental abruption. Which finding
is most characteristic of this condition?
A. Painless, bright red vaginal bleeding
B. Soft, non-tender uterus
C. Intermittent contractions with normal FHR
D. Abdominal pain with a board-like abdomen
Correct Answer: D
, Expert Explanation: Placental abruption involves the premature separation of the
placenta from the uterine wall, often causing severe pain. A board-like, rigid
abdomen is a hallmark sign caused by concealed or overt hemorrhage into the
uterine muscle. Painless bleeding is more typical of placenta previa rather than an
abruption. Distinguishing between these two conditions is vital for determining the
urgency of delivery. The nurse must prioritize monitoring for signs of maternal
shock and fetal distress in these cases.
5. A client at 30 weeks gestation is admitted for preterm labor. The physician orders
Betamethasone. What is the primary purpose of this medication?
A. To stop uterine contractions
B. To prevent maternal infection
C. To increase maternal blood pressure
D. To promote fetal lung maturity
Correct Answer: D
Expert Explanation: Betamethasone is a corticosteroid administered to mothers in
preterm labor to enhance fetal lung development. It stimulates the production of
surfactant, which reduces the risk of respiratory distress syndrome in the neonate.
This medication does not have tocolytic properties and will not stop labor
contractions. It is typically given in two doses 24 hours apart for maximum
