NUR166/NUR 166 Exam 2 V3 | Concepts of
Family Centered Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A nurse is teaching a pregnant client about the importance of folic acid. Which fetal
complication is primarily prevented by adequate folic acid intake?
A. Fetal macrosomia
B. Respiratory distress syndrome
C. Neural tube defects
D. Gestational diabetes
Correct Answer: C
Rationale: Folic acid is essential for the closure of the neural tube during the first few
weeks of pregnancy. Insufficient intake can lead to serious defects such as spina bifida
where the spinal cord fails to develop properly. The nurse should emphasize that these
defects often occur before a woman even knows she is pregnant.
2. Which clinical scenario requires the administration of Rho(D) immune globulin (RhoGAM)
to a postpartum client?
A. Rh-positive mother with an Rh-negative infant
B. Rh-negative mother with an Rh-positive infant
,C. Rh-negative mother with an Rh-negative infant
D. Rh-positive mother with an Rh-positive infant
Correct Answer: B
Rationale: RhoGAM is administered to Rh-negative mothers who give birth to Rh-positive
infants to prevent isoimmunization. This medication works by destroying fetal Rh-positive
red blood cells in the maternal circulation before the mother can develop antibodies. It is
typically administered within 72 hours of delivery to protect future pregnancies.
3. A client in labor is receiving a magnesium sulfate infusion for preeclampsia. Which
medication should the nurse have readily available at the bedside?
A. Naloxone
B. Protamine sulfate
C. Calcium gluconate
D. Terbutaline
Correct Answer: C
Rationale: Calcium gluconate is the specific antidote for magnesium sulfate toxicity. The
nurse must monitor for signs of toxicity including absent deep tendon reflexes, respiratory
depression, and decreased urine output. Having the antidote available is a standard safety
protocol whenever magnesium sulfate is infused.
, 4. A nurse is assessing a client in the third trimester who reports painless, bright red vaginal
bleeding. Which condition should the nurse suspect?
A. Abruptio placentae
B. Preterm labor
C. Placenta previa
D. Uterine rupture
Correct Answer: C
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding in the
second or third trimester. This occurs when the placenta partially or totally covers the
cervical os. In contrast, abruptio placentae typically involves painful bleeding and uterine
tenderness.
5. During a postpartum assessment, the nurse finds the client’s fundus is boggy and displaced
to the right. Which action should the nurse take first?
A. Administer oxytocin
B. Assist the client to void
C. Notify the provider
D. Perform fundal massage
Correct Answer: B
Family Centered Nursing for the Practical
Nurse Q&A with Rationale | Hondros
College of Nursing
1. A nurse is teaching a pregnant client about the importance of folic acid. Which fetal
complication is primarily prevented by adequate folic acid intake?
A. Fetal macrosomia
B. Respiratory distress syndrome
C. Neural tube defects
D. Gestational diabetes
Correct Answer: C
Rationale: Folic acid is essential for the closure of the neural tube during the first few
weeks of pregnancy. Insufficient intake can lead to serious defects such as spina bifida
where the spinal cord fails to develop properly. The nurse should emphasize that these
defects often occur before a woman even knows she is pregnant.
2. Which clinical scenario requires the administration of Rho(D) immune globulin (RhoGAM)
to a postpartum client?
A. Rh-positive mother with an Rh-negative infant
B. Rh-negative mother with an Rh-positive infant
,C. Rh-negative mother with an Rh-negative infant
D. Rh-positive mother with an Rh-positive infant
Correct Answer: B
Rationale: RhoGAM is administered to Rh-negative mothers who give birth to Rh-positive
infants to prevent isoimmunization. This medication works by destroying fetal Rh-positive
red blood cells in the maternal circulation before the mother can develop antibodies. It is
typically administered within 72 hours of delivery to protect future pregnancies.
3. A client in labor is receiving a magnesium sulfate infusion for preeclampsia. Which
medication should the nurse have readily available at the bedside?
A. Naloxone
B. Protamine sulfate
C. Calcium gluconate
D. Terbutaline
Correct Answer: C
Rationale: Calcium gluconate is the specific antidote for magnesium sulfate toxicity. The
nurse must monitor for signs of toxicity including absent deep tendon reflexes, respiratory
depression, and decreased urine output. Having the antidote available is a standard safety
protocol whenever magnesium sulfate is infused.
, 4. A nurse is assessing a client in the third trimester who reports painless, bright red vaginal
bleeding. Which condition should the nurse suspect?
A. Abruptio placentae
B. Preterm labor
C. Placenta previa
D. Uterine rupture
Correct Answer: C
Rationale: Placenta previa is characterized by painless, bright red vaginal bleeding in the
second or third trimester. This occurs when the placenta partially or totally covers the
cervical os. In contrast, abruptio placentae typically involves painful bleeding and uterine
tenderness.
5. During a postpartum assessment, the nurse finds the client’s fundus is boggy and displaced
to the right. Which action should the nurse take first?
A. Administer oxytocin
B. Assist the client to void
C. Notify the provider
D. Perform fundal massage
Correct Answer: B
