NRSG 112 Exam 1 V1 | NRSG 112
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 1) | Ivy Tech
1. A nurse is reviewing the obstetric history of a client who is currently 20 weeks pregnant.
The client had one full-term delivery at 38 weeks, one preterm delivery at 34 weeks, and one
spontaneous abortion at 10 weeks. All children are currently living. What is the correct
GTPAL?
A. G3, T1, P1, A1, L2
B. G4, T1, P2, A1, L2
C. G3, T2, P0, A1, L2
D. G4, T1, P1, A1, L2
E. G4, T2, P1, A1, L3
Correct Answer: D
The gravida (G) is 4 because it includes the current pregnancy, the term birth, the preterm
birth, and the abortion. Term (T) is 1 for the 38-week delivery, and Preterm (P) is 1 for the
34-week delivery. Abortion (A) is 1 for the spontaneous miscarriage, and Living (L) is 2 for
the two surviving children.
,2. A client in the active phase of labor presents with fetal heart rate (FHR) decelerations that
begin after the peak of the contraction and return to baseline only after the contraction has
ended. Which nursing intervention is the highest priority?
A. Increase the rate of the oxytocin infusion.
B. Turn the client to the left lateral position and administer oxygen via non-rebreather
mask.
C. Perform a vaginal exam to check for cord prolapse.
D. Instruct the client to begin pushing with the next contraction.
Correct Answer: B
Late decelerations are indicative of uteroplacental insufficiency and require immediate
intrauterine resuscitation. Repositioning the client to the side improves blood flow to the
placenta and oxygen administration increases fetal oxygen saturation. The nurse must also
discontinue oxytocin if it is infusing to reduce uterine activity.
3. When assessing a newborn 2 hours after birth, the nurse notes bluish discoloration of the
hands and feet, while the trunk remains pink. What is the nurse’s best action?
A. Notify the pediatrician of potential congenital heart disease.
B. Initiate a full septic workup immediately.
C. Apply supplemental oxygen via blow-by.
D. Document the finding as acrocyanosis and continue to monitor.
, Correct Answer: D
Acrocyanosis is a normal finding in the first 24 to 48 hours of life due to vasomotor
instability and peripheral circulatory adaptation. The nurse should verify that the central
trunk and mucous membranes are pink to rule out central cyanosis. Documentation and
routine observation are the only required actions for this benign condition.
4. A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate
infusion. Which of the following findings would indicate magnesium toxicity?
A. Blood pressure of 150/95 mmHg
B. Absence of deep tendon reflexes
C. Urinary output of 40 mL per hour
D. Fetal heart rate of 140 beats per minute
E. Increased respiratory rate of 20 breaths per minute
Correct Answer: B
The loss of deep tendon reflexes is an early clinical sign of magnesium sulfate toxicity.
Other signs include respiratory depression, decreased level of consciousness, and oliguria.
If toxicity is suspected, the nurse must stop the infusion and prepare the antidote, calcium
gluconate.
5. A pregnant client at 32 weeks gestation reports sudden, painless, bright red vaginal
bleeding. The nurse should suspect which condition?
A. Placenta previa
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 1) | Ivy Tech
1. A nurse is reviewing the obstetric history of a client who is currently 20 weeks pregnant.
The client had one full-term delivery at 38 weeks, one preterm delivery at 34 weeks, and one
spontaneous abortion at 10 weeks. All children are currently living. What is the correct
GTPAL?
A. G3, T1, P1, A1, L2
B. G4, T1, P2, A1, L2
C. G3, T2, P0, A1, L2
D. G4, T1, P1, A1, L2
E. G4, T2, P1, A1, L3
Correct Answer: D
The gravida (G) is 4 because it includes the current pregnancy, the term birth, the preterm
birth, and the abortion. Term (T) is 1 for the 38-week delivery, and Preterm (P) is 1 for the
34-week delivery. Abortion (A) is 1 for the spontaneous miscarriage, and Living (L) is 2 for
the two surviving children.
,2. A client in the active phase of labor presents with fetal heart rate (FHR) decelerations that
begin after the peak of the contraction and return to baseline only after the contraction has
ended. Which nursing intervention is the highest priority?
A. Increase the rate of the oxytocin infusion.
B. Turn the client to the left lateral position and administer oxygen via non-rebreather
mask.
C. Perform a vaginal exam to check for cord prolapse.
D. Instruct the client to begin pushing with the next contraction.
Correct Answer: B
Late decelerations are indicative of uteroplacental insufficiency and require immediate
intrauterine resuscitation. Repositioning the client to the side improves blood flow to the
placenta and oxygen administration increases fetal oxygen saturation. The nurse must also
discontinue oxytocin if it is infusing to reduce uterine activity.
3. When assessing a newborn 2 hours after birth, the nurse notes bluish discoloration of the
hands and feet, while the trunk remains pink. What is the nurse’s best action?
A. Notify the pediatrician of potential congenital heart disease.
B. Initiate a full septic workup immediately.
C. Apply supplemental oxygen via blow-by.
D. Document the finding as acrocyanosis and continue to monitor.
, Correct Answer: D
Acrocyanosis is a normal finding in the first 24 to 48 hours of life due to vasomotor
instability and peripheral circulatory adaptation. The nurse should verify that the central
trunk and mucous membranes are pink to rule out central cyanosis. Documentation and
routine observation are the only required actions for this benign condition.
4. A nurse is caring for a client with preeclampsia who is receiving a magnesium sulfate
infusion. Which of the following findings would indicate magnesium toxicity?
A. Blood pressure of 150/95 mmHg
B. Absence of deep tendon reflexes
C. Urinary output of 40 mL per hour
D. Fetal heart rate of 140 beats per minute
E. Increased respiratory rate of 20 breaths per minute
Correct Answer: B
The loss of deep tendon reflexes is an early clinical sign of magnesium sulfate toxicity.
Other signs include respiratory depression, decreased level of consciousness, and oliguria.
If toxicity is suspected, the nurse must stop the infusion and prepare the antidote, calcium
gluconate.
5. A pregnant client at 32 weeks gestation reports sudden, painless, bright red vaginal
bleeding. The nurse should suspect which condition?
A. Placenta previa
