NRSG 112 Exam 2 V1 | NRSG 112
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 2) | Ivy Tech
1. A nurse is monitoring the fetal heart rate (FHR) of a client in labor and notes variable
decelerations on the monitor strip. Which of the following causes should the nurse associate
with this pattern?
A. Fetal head compression
B. Uteroplacental insufficiency
C. Fetal hypoxia
D. Umbilical cord compression
Correct Answer: D
Variable decelerations are characterized by a sudden drop in FHR and are most commonly
associated with umbilical cord compression. This pattern requires immediate nursing
intervention such as repositioning the mother to relieve pressure on the cord. Constant
monitoring is essential to ensure that the fetal heart rate returns to baseline and that the
fetus remains stable.
2. A nurse is performing a physical assessment on a client who is 12 hours postpartum. Where
should the nurse expect to find the fundus of the uterus?
A. 2 cm above the umbilicus
,B. At the level of the umbilicus
C. 4 cm below the umbilicus
D. Halfway between the symphysis pubis and the umbilicus
Correct Answer: B
By 12 hours postpartum, the fundus should be firm and located at the level of the
umbilicus. Each subsequent day, the fundus should descend by approximately 1 to 2
centimeters as the process of involution occurs. If the fundus is higher or displaced, the
nurse must assess for a full bladder which can interfere with uterine contraction.
3. A client at 34 weeks gestation is receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following assessment findings should the nurse identify as a sign
of magnesium toxicity?
A. Absence of deep tendon reflexes
B. Respiratory rate of 14 breaths/minute
C. Blood pressure of 150/90 mmHg
D. Urinary output of 40 mL/hour
E. Presence of a mild headache
Correct Answer: A
Magnesium sulfate acts as a central nervous system depressant, and the loss of deep
tendon reflexes is one of the earliest signs of toxicity. The nurse must also monitor for a
,respiratory rate of less than 12 breaths per minute and a significant decrease in urine
output. Immediate discontinuation of the infusion and administration of calcium gluconate
is required if toxicity is suspected.
4. A newborn is receiving phototherapy for hyperbilirubinemia. Which of the following
actions should the nurse take?
A. Apply lotion to the newborn’s skin every 4 hours
B. Limit fluid intake to prevent diarrhea
C. Keep the newborn in a diaper and t-shirt
D. Cover the newborn’s eyes with an opaque mask
Correct Answer: D
It is critical to protect the newborn’s eyes from the high-intensity light used during
phototherapy to prevent retinal damage. The nurse should remove the mask only during
feedings to allow for visual stimulation and interaction with the parents. Additionally, the
nurse must monitor the infant’s temperature and hydration status closely throughout the
treatment.
5. The nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a slow/weak cry, some flexion of the extremities, grimaces when stimulated, and a
pink body with blue extremities. What is the Apgar score?
A. 5
B. 8
, C. 7
D. 6
Correct Answer: D
The Apgar score is calculated as follows: Heart rate >100 (2), slow/weak cry (1), flexion
(1), grimace (1), and pink body with blue extremities (1), totaling 6. A score between 4 and
6 indicates that the newborn is having some difficulty adjusting and requires close
observation. This assessment is repeated at the 5-minute mark to evaluate the
effectiveness of any interventions.
6. A nurse is providing teaching to a new mother about why her newborn is receiving a
Vitamin K injection. Which statement should the nurse include?
A. It prevents the development of physiological jaundice
B. It stimulates the production of red blood cells
C. It boosts the infant’s immune system against infections
D. It provides the necessary factors for blood clotting
Correct Answer: D
Newborns are born with a sterile gut and lack the intestinal flora needed to synthesize
Vitamin K, which is vital for the production of clotting factors. Administering an
intramuscular injection of Vitamin K shortly after birth prevents Vitamin K deficiency
bleeding. This standard of care ensures the newborn’s safety during the first week of life
before they can produce their own.
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 2) | Ivy Tech
1. A nurse is monitoring the fetal heart rate (FHR) of a client in labor and notes variable
decelerations on the monitor strip. Which of the following causes should the nurse associate
with this pattern?
A. Fetal head compression
B. Uteroplacental insufficiency
C. Fetal hypoxia
D. Umbilical cord compression
Correct Answer: D
Variable decelerations are characterized by a sudden drop in FHR and are most commonly
associated with umbilical cord compression. This pattern requires immediate nursing
intervention such as repositioning the mother to relieve pressure on the cord. Constant
monitoring is essential to ensure that the fetal heart rate returns to baseline and that the
fetus remains stable.
2. A nurse is performing a physical assessment on a client who is 12 hours postpartum. Where
should the nurse expect to find the fundus of the uterus?
A. 2 cm above the umbilicus
,B. At the level of the umbilicus
C. 4 cm below the umbilicus
D. Halfway between the symphysis pubis and the umbilicus
Correct Answer: B
By 12 hours postpartum, the fundus should be firm and located at the level of the
umbilicus. Each subsequent day, the fundus should descend by approximately 1 to 2
centimeters as the process of involution occurs. If the fundus is higher or displaced, the
nurse must assess for a full bladder which can interfere with uterine contraction.
3. A client at 34 weeks gestation is receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following assessment findings should the nurse identify as a sign
of magnesium toxicity?
A. Absence of deep tendon reflexes
B. Respiratory rate of 14 breaths/minute
C. Blood pressure of 150/90 mmHg
D. Urinary output of 40 mL/hour
E. Presence of a mild headache
Correct Answer: A
Magnesium sulfate acts as a central nervous system depressant, and the loss of deep
tendon reflexes is one of the earliest signs of toxicity. The nurse must also monitor for a
,respiratory rate of less than 12 breaths per minute and a significant decrease in urine
output. Immediate discontinuation of the infusion and administration of calcium gluconate
is required if toxicity is suspected.
4. A newborn is receiving phototherapy for hyperbilirubinemia. Which of the following
actions should the nurse take?
A. Apply lotion to the newborn’s skin every 4 hours
B. Limit fluid intake to prevent diarrhea
C. Keep the newborn in a diaper and t-shirt
D. Cover the newborn’s eyes with an opaque mask
Correct Answer: D
It is critical to protect the newborn’s eyes from the high-intensity light used during
phototherapy to prevent retinal damage. The nurse should remove the mask only during
feedings to allow for visual stimulation and interaction with the parents. Additionally, the
nurse must monitor the infant’s temperature and hydration status closely throughout the
treatment.
5. The nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a slow/weak cry, some flexion of the extremities, grimaces when stimulated, and a
pink body with blue extremities. What is the Apgar score?
A. 5
B. 8
, C. 7
D. 6
Correct Answer: D
The Apgar score is calculated as follows: Heart rate >100 (2), slow/weak cry (1), flexion
(1), grimace (1), and pink body with blue extremities (1), totaling 6. A score between 4 and
6 indicates that the newborn is having some difficulty adjusting and requires close
observation. This assessment is repeated at the 5-minute mark to evaluate the
effectiveness of any interventions.
6. A nurse is providing teaching to a new mother about why her newborn is receiving a
Vitamin K injection. Which statement should the nurse include?
A. It prevents the development of physiological jaundice
B. It stimulates the production of red blood cells
C. It boosts the infant’s immune system against infections
D. It provides the necessary factors for blood clotting
Correct Answer: D
Newborns are born with a sterile gut and lack the intestinal flora needed to synthesize
Vitamin K, which is vital for the production of clotting factors. Administering an
intramuscular injection of Vitamin K shortly after birth prevents Vitamin K deficiency
bleeding. This standard of care ensures the newborn’s safety during the first week of life
before they can produce their own.
