NRSG 112 Exam 2 V2 | NRSG 112
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 2) | Ivy Tech
1. A nurse is assessing a client who is at 36 weeks of gestation and has preeclampsia. Which
of the following findings should the nurse identify as a priority?
A. Non-reactive stress test
B. 1+ edema in the lower extremities
C. Report of a mild headache
D. Urinary protein of 300 mg/24 hr
Correct Answer: A
A non-reactive stress test indicates potential fetal compromise and requires immediate
further evaluation or intervention. While edema and proteinuria are common findings in
preeclampsia, they are not as immediately concerning as a non-reassuring fetal status. A
mild headache should be monitored, but a non-reactive stress test takes priority in the
context of placental perfusion concerns.
2. A nurse is caring for a client in the second stage of labor. Which of the following
interventions should the nurse prioritize to promote fetal oxygenation?
A. Encourage the client to push using the Valsalva maneuver
B. Perform frequent vaginal exams
,C. Administer an opioid analgesic for pain relief
D. Position the client in a lateral or upright position
E. Keep the client in a supine position to facilitate delivery
Correct Answer: D
Positioning the client in a lateral or upright position helps prevent aortocaval
compression, which optimizes uterine blood flow and fetal oxygenation. The Valsalva
maneuver can actually decrease oxygen delivery to the fetus by increasing intrathoracic
pressure. Maintaining a supine position is contraindicated as it can lead to maternal
hypotension and reduced placental perfusion.
3. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings is the first sign of magnesium toxicity?
A. Decrease in respiratory rate below 10/min
B. Change in mental status or confusion
C. Urinary output of 20 mL/hr
D. Loss of deep tendon reflexes
Correct Answer: D
The loss of deep tendon reflexes is typically the first clinical sign of magnesium sulfate
toxicity. Respiratory depression and cardiac arrest occur later at higher serum levels of the
, medication. The nurse must assess reflexes hourly to ensure the client remains within the
therapeutic range.
4. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Milia on the nose and chin
B. Acrocyanosis of the hands and feet
C. Vernix caseosa in the skin folds
D. Generalized petechiae over the trunk
Correct Answer: D
Generalized petechiae can indicate a clotting factor deficiency or infection and must be
reported to the provider immediately. Acrocyanosis is a normal finding in the first 24 to 48
hours of life due to poor peripheral circulation. Vernix caseosa and milia are also normal
physical findings in a term newborn.
5. A nurse is monitoring a client in labor and notes late decelerations on the fetal monitor.
Which of the following actions should the nurse take?
A. Decrease the rate of the IV maintenance fluids
B. Prepare the client for an immediate vacuum-assisted delivery
C. Administer oxygen via a non-rebreather face mask at 8 to 10 L/min
D. Place the client in a Trendelenburg position
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 2) | Ivy Tech
1. A nurse is assessing a client who is at 36 weeks of gestation and has preeclampsia. Which
of the following findings should the nurse identify as a priority?
A. Non-reactive stress test
B. 1+ edema in the lower extremities
C. Report of a mild headache
D. Urinary protein of 300 mg/24 hr
Correct Answer: A
A non-reactive stress test indicates potential fetal compromise and requires immediate
further evaluation or intervention. While edema and proteinuria are common findings in
preeclampsia, they are not as immediately concerning as a non-reassuring fetal status. A
mild headache should be monitored, but a non-reactive stress test takes priority in the
context of placental perfusion concerns.
2. A nurse is caring for a client in the second stage of labor. Which of the following
interventions should the nurse prioritize to promote fetal oxygenation?
A. Encourage the client to push using the Valsalva maneuver
B. Perform frequent vaginal exams
,C. Administer an opioid analgesic for pain relief
D. Position the client in a lateral or upright position
E. Keep the client in a supine position to facilitate delivery
Correct Answer: D
Positioning the client in a lateral or upright position helps prevent aortocaval
compression, which optimizes uterine blood flow and fetal oxygenation. The Valsalva
maneuver can actually decrease oxygen delivery to the fetus by increasing intrathoracic
pressure. Maintaining a supine position is contraindicated as it can lead to maternal
hypotension and reduced placental perfusion.
3. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings is the first sign of magnesium toxicity?
A. Decrease in respiratory rate below 10/min
B. Change in mental status or confusion
C. Urinary output of 20 mL/hr
D. Loss of deep tendon reflexes
Correct Answer: D
The loss of deep tendon reflexes is typically the first clinical sign of magnesium sulfate
toxicity. Respiratory depression and cardiac arrest occur later at higher serum levels of the
, medication. The nurse must assess reflexes hourly to ensure the client remains within the
therapeutic range.
4. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Milia on the nose and chin
B. Acrocyanosis of the hands and feet
C. Vernix caseosa in the skin folds
D. Generalized petechiae over the trunk
Correct Answer: D
Generalized petechiae can indicate a clotting factor deficiency or infection and must be
reported to the provider immediately. Acrocyanosis is a normal finding in the first 24 to 48
hours of life due to poor peripheral circulation. Vernix caseosa and milia are also normal
physical findings in a term newborn.
5. A nurse is monitoring a client in labor and notes late decelerations on the fetal monitor.
Which of the following actions should the nurse take?
A. Decrease the rate of the IV maintenance fluids
B. Prepare the client for an immediate vacuum-assisted delivery
C. Administer oxygen via a non-rebreather face mask at 8 to 10 L/min
D. Place the client in a Trendelenburg position
