NRSG 112 Exam 3 V2 | NRSG 112
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 3) | Ivy Tech
1. A nurse is monitoring a client in the second stage of labor who is experiencing late
decelerations on the fetal heart rate monitor. Which of the following initial nursing
interventions is the highest priority?
A. Increase the rate of the oxytocin infusion
B. Prepare the client for an immediate forceps-assisted delivery
C. Reposition the client to a lateral position
D. Perform a vaginal examination to check for cord prolapse
E. Administer oxygen at 2 liters via nasal cannula
Correct Answer: C
Late decelerations are indicative of uteroplacental insufficiency and require immediate
intervention to improve blood flow. The first step the nurse should take is to turn the
patient to their side to relieve pressure on the vena cava and improve placental perfusion.
Following this action, the nurse should also discontinue oxytocin if it is infusing and
consider oxygen administration via a non-rebreather mask.
,2. A postpartum nurse is assessing a client 4 hours after a vaginal delivery. The client’s fundus
is firm, two fingerbreadths above the umbilicus, and deviated to the right. Which action
should the nurse take?
A. Massage the fundus vigorously
B. Administer 0.2 mg of methylergonovine intramuscularly
C. Notify the healthcare provider of a potential hemorrhage
D. Assist the client to the bathroom to void
Correct Answer: D
A fundus that is displaced upward and to the right is a classic sign of bladder distention. A
full bladder prevents the uterus from contracting efficiently, which increases the risk of
uterine atony and subsequent hemorrhage. Once the client voids, the fundus should return
to the midline and descend to the level of the umbilicus or below.
3. A nurse is caring for a client receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following findings should the nurse identify as a sign of
magnesium toxicity?
A. Hyperreflexia (4+ deep tendon reflexes)
B. Urine output of 40 mL per hour
C. Increased fetal heart rate variability
D. Respiratory rate of 10 breaths per minute
,Correct Answer: D
Magnesium sulfate acts as a central nervous system depressant, and toxicity can lead to
respiratory depression, typically defined as fewer than 12 breaths per minute. Other signs
of toxicity include the loss of deep tendon reflexes and decreased urinary output, which can
lead to further accumulation of the drug. If toxicity is suspected, the infusion must be
stopped immediately and the antidote, calcium gluconate, should be prepared.
4. The nurse is evaluating the Apgar score of a newborn at 1 minute. The infant has a heart
rate of 110 bpm, a weak cry, some flexion of the extremities, grimacing, and a pink body with
blue extremities. What is the Apgar score?
A. 6
B. 5
C. 7
D. 8
Correct Answer: A
The score is calculated as follows: Heart rate over 100 gets 2 points; weak cry (respiratory
effort) gets 1 point; some flexion (muscle tone) gets 1 point; grimace (reflex irritability)
gets 1 point; and pink body with blue extremities (acrocyanosis) gets 1 point. Totaling
these gives a score of 6. This indicates the newborn is having some difficulty adjusting and
requires close monitoring and potential intervention.
, 5. A nurse is providing discharge instructions to a client who is breastfeeding. Which
statement by the client indicates an understanding of how to prevent mastitis?
A. I will limit my fluid intake to prevent breast engorgement
B. I will ensure my baby is latched correctly and change feeding positions
C. I should wear a tight-fitting underwire bra for support
D. I will wait at least 6 hours between feedings to rest my nipples
Correct Answer: B
Mastitis is often caused by milk stasis or bacteria entering through cracked nipples, both
of which can be prevented by proper latch and frequent emptying of the breasts. Changing
positions ensures all milk ducts are drained effectively during feedings. Clients should
avoid tight bras and skipping feedings, as these factors contribute to ductal clogging and
infection.
6. A nurse is assessing a newborn 12 hours after birth. Which of the following findings
requires immediate notification of the healthcare provider?
A. Generalized petechiae on the trunk
B. Acrocyanosis of the hands and feet
C. Erythema toxicum on the chest
D. Milia on the bridge of the nose
Correct Answer: A
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 3) | Ivy Tech
1. A nurse is monitoring a client in the second stage of labor who is experiencing late
decelerations on the fetal heart rate monitor. Which of the following initial nursing
interventions is the highest priority?
A. Increase the rate of the oxytocin infusion
B. Prepare the client for an immediate forceps-assisted delivery
C. Reposition the client to a lateral position
D. Perform a vaginal examination to check for cord prolapse
E. Administer oxygen at 2 liters via nasal cannula
Correct Answer: C
Late decelerations are indicative of uteroplacental insufficiency and require immediate
intervention to improve blood flow. The first step the nurse should take is to turn the
patient to their side to relieve pressure on the vena cava and improve placental perfusion.
Following this action, the nurse should also discontinue oxytocin if it is infusing and
consider oxygen administration via a non-rebreather mask.
,2. A postpartum nurse is assessing a client 4 hours after a vaginal delivery. The client’s fundus
is firm, two fingerbreadths above the umbilicus, and deviated to the right. Which action
should the nurse take?
A. Massage the fundus vigorously
B. Administer 0.2 mg of methylergonovine intramuscularly
C. Notify the healthcare provider of a potential hemorrhage
D. Assist the client to the bathroom to void
Correct Answer: D
A fundus that is displaced upward and to the right is a classic sign of bladder distention. A
full bladder prevents the uterus from contracting efficiently, which increases the risk of
uterine atony and subsequent hemorrhage. Once the client voids, the fundus should return
to the midline and descend to the level of the umbilicus or below.
3. A nurse is caring for a client receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following findings should the nurse identify as a sign of
magnesium toxicity?
A. Hyperreflexia (4+ deep tendon reflexes)
B. Urine output of 40 mL per hour
C. Increased fetal heart rate variability
D. Respiratory rate of 10 breaths per minute
,Correct Answer: D
Magnesium sulfate acts as a central nervous system depressant, and toxicity can lead to
respiratory depression, typically defined as fewer than 12 breaths per minute. Other signs
of toxicity include the loss of deep tendon reflexes and decreased urinary output, which can
lead to further accumulation of the drug. If toxicity is suspected, the infusion must be
stopped immediately and the antidote, calcium gluconate, should be prepared.
4. The nurse is evaluating the Apgar score of a newborn at 1 minute. The infant has a heart
rate of 110 bpm, a weak cry, some flexion of the extremities, grimacing, and a pink body with
blue extremities. What is the Apgar score?
A. 6
B. 5
C. 7
D. 8
Correct Answer: A
The score is calculated as follows: Heart rate over 100 gets 2 points; weak cry (respiratory
effort) gets 1 point; some flexion (muscle tone) gets 1 point; grimace (reflex irritability)
gets 1 point; and pink body with blue extremities (acrocyanosis) gets 1 point. Totaling
these gives a score of 6. This indicates the newborn is having some difficulty adjusting and
requires close monitoring and potential intervention.
, 5. A nurse is providing discharge instructions to a client who is breastfeeding. Which
statement by the client indicates an understanding of how to prevent mastitis?
A. I will limit my fluid intake to prevent breast engorgement
B. I will ensure my baby is latched correctly and change feeding positions
C. I should wear a tight-fitting underwire bra for support
D. I will wait at least 6 hours between feedings to rest my nipples
Correct Answer: B
Mastitis is often caused by milk stasis or bacteria entering through cracked nipples, both
of which can be prevented by proper latch and frequent emptying of the breasts. Changing
positions ensures all milk ducts are drained effectively during feedings. Clients should
avoid tight bras and skipping feedings, as these factors contribute to ductal clogging and
infection.
6. A nurse is assessing a newborn 12 hours after birth. Which of the following findings
requires immediate notification of the healthcare provider?
A. Generalized petechiae on the trunk
B. Acrocyanosis of the hands and feet
C. Erythema toxicum on the chest
D. Milia on the bridge of the nose
Correct Answer: A
