NUR254 | NUR254 Concepts of Nursing; The
Childbearing and Child Caring Families Exam 3
Version 1 Questions with Correct Answers and
Expert Explanation for Each Question
1. A nurse is caring for a patient in the active phase of the first stage of labor. The
nurse notes that the cervix is dilated to 6 cm. What is the expected rate of cervical
dilation for a primiparous woman during this phase?
A. 0.5 cm per hour
B. 2.0 cm per hour
C. 1.2 cm per hour
D. 3.5 cm per hour
Correct Answer: C
Expert Explanation: In the active phase of labor, the cervix typically dilates at a
predictable rate for primiparous women. This rate is generally accepted as
approximately 1.2 cm per hour until full dilation is achieved. For multiparous
women, the rate is often faster, averaging about 1.5 cm per hour. Monitoring this
progress helps the nurse identify potential labor dystocia or deviations from the
normal labor curve. Understanding these norms allows for timely interventions and
appropriate support for the laboring mother.
,2. During fetal monitoring, the nurse observes a pattern of late decelerations on the
electronic fetal monitor. Which action should the nurse take first?
A. Increase the rate of the oxytocin (Pitocin) infusion
B. Reposition the patient to a lateral side-lying position
C. Administer oxygen at 8 to 10 L/min via non-rebreather mask
D. Assist the patient into a supine position
Correct Answer: B
Expert Explanation: Late decelerations are indicative of uteroplacental
insufficiency and require immediate nursing intervention to improve fetal
oxygenation. The primary action is to reposition the mother to a side-lying position
to relieve pressure on the vena cava and increase placental perfusion. Following
this, the nurse should discontinue oxytocin if it is being administered to reduce
uterine stress. Oxygen administration and increasing intravenous fluid rates are also
standard components of intrauterine resuscitation. Promptly addressing these
patterns is vital to prevent fetal hypoxia and acidosis.
,3. A newborn is assessed at 1 minute after birth. The infant has a heart rate of 110
bpm, a slow and irregular respiratory effort, some flexion of the extremities, a grimace
in response to a catheter in the nostril, and a body that is pink with blue extremities.
What is the APGAR score?
A. 6
B. 5
C. 7
D. 8
Correct Answer: A
Expert Explanation: The APGAR score evaluates five categories including heart
rate, respiration, muscle tone, reflex irritability, and color. This infant receives 2
points for heart rate, 1 for respiration, 1 for muscle tone, 1 for reflex, and 1 for color.
Adding these values results in a total score of 6, indicating the need for some
intervention. Scores between 4 and 6 suggest that the neonate is having moderate
difficulty adjusting to extrauterine life. The nurse must continue to monitor and
provide necessary support like tactile stimulation or oxygen.
4. A nurse is monitoring a patient receiving Magnesium Sulfate for pre-eclampsia.
Which of the following findings would indicate Magnesium toxicity?
A. Blood pressure of 150/95 mmHg
, B. Absence of deep tendon reflexes (DTRs)
C. Increased urinary output
D. Respiratory rate of 18 breaths per minute
Correct Answer: B
Expert Explanation: Magnesium Sulfate is used to prevent seizures in pre-
eclamptic patients but carries a high risk of toxicity. The loss of deep tendon reflexes
is one of the earliest signs that magnesium levels are becoming dangerously high.
Other signs of toxicity include respiratory depression, decreased urine output, and
cardiac arrest. The nurse must keep Calcium Gluconate at the bedside as the specific
antidote for magnesium toxicity. Frequent assessment of reflexes and respiratory
status is mandatory for any patient receiving this high-alert medication.
5. Which clinical finding is most characteristic of the transition phase of the first stage
of labor?
A. Cervical dilation of 3 cm
B. Decreased bloody show
C. Maternal statements of feeling in control
D. Strong contractions every 2 to 3 minutes
Correct Answer: D
Childbearing and Child Caring Families Exam 3
Version 1 Questions with Correct Answers and
Expert Explanation for Each Question
1. A nurse is caring for a patient in the active phase of the first stage of labor. The
nurse notes that the cervix is dilated to 6 cm. What is the expected rate of cervical
dilation for a primiparous woman during this phase?
A. 0.5 cm per hour
B. 2.0 cm per hour
C. 1.2 cm per hour
D. 3.5 cm per hour
Correct Answer: C
Expert Explanation: In the active phase of labor, the cervix typically dilates at a
predictable rate for primiparous women. This rate is generally accepted as
approximately 1.2 cm per hour until full dilation is achieved. For multiparous
women, the rate is often faster, averaging about 1.5 cm per hour. Monitoring this
progress helps the nurse identify potential labor dystocia or deviations from the
normal labor curve. Understanding these norms allows for timely interventions and
appropriate support for the laboring mother.
,2. During fetal monitoring, the nurse observes a pattern of late decelerations on the
electronic fetal monitor. Which action should the nurse take first?
A. Increase the rate of the oxytocin (Pitocin) infusion
B. Reposition the patient to a lateral side-lying position
C. Administer oxygen at 8 to 10 L/min via non-rebreather mask
D. Assist the patient into a supine position
Correct Answer: B
Expert Explanation: Late decelerations are indicative of uteroplacental
insufficiency and require immediate nursing intervention to improve fetal
oxygenation. The primary action is to reposition the mother to a side-lying position
to relieve pressure on the vena cava and increase placental perfusion. Following
this, the nurse should discontinue oxytocin if it is being administered to reduce
uterine stress. Oxygen administration and increasing intravenous fluid rates are also
standard components of intrauterine resuscitation. Promptly addressing these
patterns is vital to prevent fetal hypoxia and acidosis.
,3. A newborn is assessed at 1 minute after birth. The infant has a heart rate of 110
bpm, a slow and irregular respiratory effort, some flexion of the extremities, a grimace
in response to a catheter in the nostril, and a body that is pink with blue extremities.
What is the APGAR score?
A. 6
B. 5
C. 7
D. 8
Correct Answer: A
Expert Explanation: The APGAR score evaluates five categories including heart
rate, respiration, muscle tone, reflex irritability, and color. This infant receives 2
points for heart rate, 1 for respiration, 1 for muscle tone, 1 for reflex, and 1 for color.
Adding these values results in a total score of 6, indicating the need for some
intervention. Scores between 4 and 6 suggest that the neonate is having moderate
difficulty adjusting to extrauterine life. The nurse must continue to monitor and
provide necessary support like tactile stimulation or oxygen.
4. A nurse is monitoring a patient receiving Magnesium Sulfate for pre-eclampsia.
Which of the following findings would indicate Magnesium toxicity?
A. Blood pressure of 150/95 mmHg
, B. Absence of deep tendon reflexes (DTRs)
C. Increased urinary output
D. Respiratory rate of 18 breaths per minute
Correct Answer: B
Expert Explanation: Magnesium Sulfate is used to prevent seizures in pre-
eclamptic patients but carries a high risk of toxicity. The loss of deep tendon reflexes
is one of the earliest signs that magnesium levels are becoming dangerously high.
Other signs of toxicity include respiratory depression, decreased urine output, and
cardiac arrest. The nurse must keep Calcium Gluconate at the bedside as the specific
antidote for magnesium toxicity. Frequent assessment of reflexes and respiratory
status is mandatory for any patient receiving this high-alert medication.
5. Which clinical finding is most characteristic of the transition phase of the first stage
of labor?
A. Cervical dilation of 3 cm
B. Decreased bloody show
C. Maternal statements of feeling in control
D. Strong contractions every 2 to 3 minutes
Correct Answer: D
