NRSG 112 Exam 3 V3 | NRSG 112
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 3) | Ivy Tech
1. A nurse is assessing a postpartum client 2 hours after delivery and finds the fundus is boggy
and displaced to the right. What is the priority nursing action?
A. Massage the fundus until firm.
B. Notify the healthcare provider immediately.
C. Administer oxytocin as ordered.
D. Assist the client to the bathroom to void.
Correct Answer: D
A displaced fundus to the right usually indicates a distended bladder, which prevents the
uterus from contracting effectively. Assisting the client to void is the priority to allow the
uterus to return to the midline and contract. While fundal massage is important for
bogginess, the displacement must be addressed first by emptying the bladder.
2. A newborn is being evaluated using the APGAR scoring system at 1 minute of life. The
heart rate is 110 bpm, the cry is weak, there is some flexion of the extremities, the baby
grimaces when suctioned, and the body is pink with blue extremities. What is the APGAR
score?
A. 5
,B. 7
C. 6
D. 8
Correct Answer: C
The score is calculated as follows: Heart rate > 100 (2 points), Weak cry (1 point), Some
flexion (1 point), Grimace (1 point), and Acrocyanosis (1 point). This totals a score of 6,
which indicates the infant may require some resuscitation or closer observation. APGAR
scores are traditionally assessed at 1 and 5 minutes to evaluate the newborn’s transition to
extrauterine life.
3. A nurse is teaching a group of parents about infant safety. Which of the following
instructions should be included to prevent Sudden Infant Death Syndrome (SIDS)?
A. Place the infant in a side-lying position for sleep.
B. Use soft pillows and quilts in the crib for comfort.
C. Place the infant in a supine position on a firm mattress.
D. Keep the nursery temperature at least 75 degrees Fahrenheit.
Correct Answer: C
The ‘Back to Sleep’ campaign recommends the supine position as the safest sleeping
posture for infants to reduce the risk of SIDS. The sleeping surface should be firm and free
, of soft objects, toys, or loose bedding that could cause suffocation. Overheating should also
be avoided, as it is a known risk factor for SIDS.
4. The nurse is assessing a 36-hour-old newborn for signs of respiratory distress. Which of the
following findings should be reported to the provider? (Select all that apply)
A. Acrocyanosis
B. Nasal flaring
C. Sternal retractions
D. Expiratory grunting
E. Respiratory rate of 45 breaths/min
F. Tachypnea greater than 60 breaths/min
Correct Answer: B, C, D, F
Nasal flaring, retractions, and grunting are classic signs of increased work of breathing
and respiratory distress in the neonate. Tachypnea, defined as a respiratory rate over 60, is
an early compensatory mechanism for hypoxia. Acrocyanosis and a respiratory rate of 45
are considered normal findings in a newborn during the first few days of life.
5. A nurse is providing discharge teaching to the mother of a newborn with physiologic
jaundice who is being treated with phototherapy at home. Which statement by the mother
indicates a need for further teaching?
A. I will keep the baby’s eyes covered while under the lights.
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 3) | Ivy Tech
1. A nurse is assessing a postpartum client 2 hours after delivery and finds the fundus is boggy
and displaced to the right. What is the priority nursing action?
A. Massage the fundus until firm.
B. Notify the healthcare provider immediately.
C. Administer oxytocin as ordered.
D. Assist the client to the bathroom to void.
Correct Answer: D
A displaced fundus to the right usually indicates a distended bladder, which prevents the
uterus from contracting effectively. Assisting the client to void is the priority to allow the
uterus to return to the midline and contract. While fundal massage is important for
bogginess, the displacement must be addressed first by emptying the bladder.
2. A newborn is being evaluated using the APGAR scoring system at 1 minute of life. The
heart rate is 110 bpm, the cry is weak, there is some flexion of the extremities, the baby
grimaces when suctioned, and the body is pink with blue extremities. What is the APGAR
score?
A. 5
,B. 7
C. 6
D. 8
Correct Answer: C
The score is calculated as follows: Heart rate > 100 (2 points), Weak cry (1 point), Some
flexion (1 point), Grimace (1 point), and Acrocyanosis (1 point). This totals a score of 6,
which indicates the infant may require some resuscitation or closer observation. APGAR
scores are traditionally assessed at 1 and 5 minutes to evaluate the newborn’s transition to
extrauterine life.
3. A nurse is teaching a group of parents about infant safety. Which of the following
instructions should be included to prevent Sudden Infant Death Syndrome (SIDS)?
A. Place the infant in a side-lying position for sleep.
B. Use soft pillows and quilts in the crib for comfort.
C. Place the infant in a supine position on a firm mattress.
D. Keep the nursery temperature at least 75 degrees Fahrenheit.
Correct Answer: C
The ‘Back to Sleep’ campaign recommends the supine position as the safest sleeping
posture for infants to reduce the risk of SIDS. The sleeping surface should be firm and free
, of soft objects, toys, or loose bedding that could cause suffocation. Overheating should also
be avoided, as it is a known risk factor for SIDS.
4. The nurse is assessing a 36-hour-old newborn for signs of respiratory distress. Which of the
following findings should be reported to the provider? (Select all that apply)
A. Acrocyanosis
B. Nasal flaring
C. Sternal retractions
D. Expiratory grunting
E. Respiratory rate of 45 breaths/min
F. Tachypnea greater than 60 breaths/min
Correct Answer: B, C, D, F
Nasal flaring, retractions, and grunting are classic signs of increased work of breathing
and respiratory distress in the neonate. Tachypnea, defined as a respiratory rate over 60, is
an early compensatory mechanism for hypoxia. Acrocyanosis and a respiratory rate of 45
are considered normal findings in a newborn during the first few days of life.
5. A nurse is providing discharge teaching to the mother of a newborn with physiologic
jaundice who is being treated with phototherapy at home. Which statement by the mother
indicates a need for further teaching?
A. I will keep the baby’s eyes covered while under the lights.
