NUR 230 Exam 2: OB/Peds - Galen College of Nursing
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is monitoring a client in labor and notices late decelerations on the fetal monitor. Which action
should the nurse take first?
A. Administer oxygen at 10 liters via face mask
B. Notify the healthcare provider immediately
C. Increase the rate of the intravenous fluids
D. Reposition the client to the left lateral position
Correct Answer: D
Rationale: Late decelerations are indicative of uteroplacental insufficiency and are considered non-
reassuring. The first action the nurse should take is to reposition the mother to improve blood flow to the
placenta. This simple change can often resolve the deceleration by removing pressure from the vena cava.
Oxygen and fluid boluses are secondary interventions that support fetal oxygenation. The provider is
notified after initial corrective measures are implemented.
2. Which assessment finding is most characteristic of a patient in the transition phase of the first stage of
labor?
A. Cervical dilation of 3 to 5 centimeters
B. Passage of a thick, bloody mucus plug
C. The onset of mild, irregular contractions
D. Increased urge to push and irritability
Correct Answer: D
,Rationale: The transition phase occurs when the cervix dilates from 8 to 10 centimeters. During this
time, the patient often experiences intense pressure and an urge to push. Psychological changes include
irritability, loss of control, and extreme focus. This is the shortest but most physically demanding part of
the first stage. Nursing care focuses on coaching the patient through each intense contraction.
3. A nurse is caring for a patient receiving Magnesium Sulfate for preeclampsia. What finding would indicate
magnesium toxicity?
A. Hyperactive deep tendon reflexes
B. Urine output of 40 mL per hour
C. Increased maternal blood pressure
D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Rationale: Magnesium sulfate acts as a central nervous system depressant to prevent seizures. A
respiratory rate below 12 breaths per minute is a clear sign of toxicity. Other signs include absent deep
tendon reflexes and decreased levels of consciousness. The nurse must stop the infusion immediately if
these signs are noted. Calcium gluconate should be kept at the bedside to reverse these effects.
4. A client presents at 32 weeks gestation with painless, bright red vaginal bleeding. Which condition should
the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Preterm labor
D. Cervical polyps
Correct Answer: B
, Rationale: Placenta previa is characterized by the placenta covering the cervical os either partially or
completely. The classic presentation is painless, bright red vaginal bleeding during the third trimester.
This differs from placental abruption, which is usually associated with severe abdominal pain. Digital
vaginal exams are strictly contraindicated until the location of the placenta is confirmed by ultrasound.
The nurse must monitor maternal vital signs and fetal heart rate closely.
5. What is the primary cause of variable decelerations on a fetal heart rate monitor?
A. Head compression during contractions
B. Uteroplacental insufficiency
C. Umbilical cord compression
D. Maternal hypotension after an epidural
Correct Answer: C
Rationale: Variable decelerations are abrupt decreases in fetal heart rate that vary in shape and timing.
They are caused by the compression of the umbilical cord during contractions or fetal movement. These
decelerations often look like a ‘V’, ‘U’, or ‘W’ on the monitor strip. Nursing interventions involve changing
the maternal position to relieve the pressure on the cord. If the pattern persists, further evaluation of
fetal well-being is required.
6. A nurse performs Leopold maneuvers on a pregnant client. What is the primary purpose of this
assessment?
A. To determine fetal presentation and position
B. To estimate the volume of amniotic fluid
C. To assess for the presence of uterine contractions
D. To measure the height of the uterine fundus
Updated and Latest Questions and Correct Answers with
Rationale
1. A nurse is monitoring a client in labor and notices late decelerations on the fetal monitor. Which action
should the nurse take first?
A. Administer oxygen at 10 liters via face mask
B. Notify the healthcare provider immediately
C. Increase the rate of the intravenous fluids
D. Reposition the client to the left lateral position
Correct Answer: D
Rationale: Late decelerations are indicative of uteroplacental insufficiency and are considered non-
reassuring. The first action the nurse should take is to reposition the mother to improve blood flow to the
placenta. This simple change can often resolve the deceleration by removing pressure from the vena cava.
Oxygen and fluid boluses are secondary interventions that support fetal oxygenation. The provider is
notified after initial corrective measures are implemented.
2. Which assessment finding is most characteristic of a patient in the transition phase of the first stage of
labor?
A. Cervical dilation of 3 to 5 centimeters
B. Passage of a thick, bloody mucus plug
C. The onset of mild, irregular contractions
D. Increased urge to push and irritability
Correct Answer: D
,Rationale: The transition phase occurs when the cervix dilates from 8 to 10 centimeters. During this
time, the patient often experiences intense pressure and an urge to push. Psychological changes include
irritability, loss of control, and extreme focus. This is the shortest but most physically demanding part of
the first stage. Nursing care focuses on coaching the patient through each intense contraction.
3. A nurse is caring for a patient receiving Magnesium Sulfate for preeclampsia. What finding would indicate
magnesium toxicity?
A. Hyperactive deep tendon reflexes
B. Urine output of 40 mL per hour
C. Increased maternal blood pressure
D. Respiratory rate of 10 breaths per minute
Correct Answer: D
Rationale: Magnesium sulfate acts as a central nervous system depressant to prevent seizures. A
respiratory rate below 12 breaths per minute is a clear sign of toxicity. Other signs include absent deep
tendon reflexes and decreased levels of consciousness. The nurse must stop the infusion immediately if
these signs are noted. Calcium gluconate should be kept at the bedside to reverse these effects.
4. A client presents at 32 weeks gestation with painless, bright red vaginal bleeding. Which condition should
the nurse suspect?
A. Abruptio placentae
B. Placenta previa
C. Preterm labor
D. Cervical polyps
Correct Answer: B
, Rationale: Placenta previa is characterized by the placenta covering the cervical os either partially or
completely. The classic presentation is painless, bright red vaginal bleeding during the third trimester.
This differs from placental abruption, which is usually associated with severe abdominal pain. Digital
vaginal exams are strictly contraindicated until the location of the placenta is confirmed by ultrasound.
The nurse must monitor maternal vital signs and fetal heart rate closely.
5. What is the primary cause of variable decelerations on a fetal heart rate monitor?
A. Head compression during contractions
B. Uteroplacental insufficiency
C. Umbilical cord compression
D. Maternal hypotension after an epidural
Correct Answer: C
Rationale: Variable decelerations are abrupt decreases in fetal heart rate that vary in shape and timing.
They are caused by the compression of the umbilical cord during contractions or fetal movement. These
decelerations often look like a ‘V’, ‘U’, or ‘W’ on the monitor strip. Nursing interventions involve changing
the maternal position to relieve the pressure on the cord. If the pattern persists, further evaluation of
fetal well-being is required.
6. A nurse performs Leopold maneuvers on a pregnant client. What is the primary purpose of this
assessment?
A. To determine fetal presentation and position
B. To estimate the volume of amniotic fluid
C. To assess for the presence of uterine contractions
D. To measure the height of the uterine fundus
