NRSG 112 Exam 2 V3 | NRSG 112
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 2) | Ivy Tech
1. A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which of the
following findings should the nurse report to the provider immediately?
A. Respiratory rate of 10/min
B. Urinary output of 40 mL/hr
C. Presence of 2+ deep tendon reflexes
D. Blood pressure of 148/96 mmHg
Correct Answer: A
Magnesium sulfate is a central nervous system depressant used to prevent seizures in
preeclampsia, but it carries a high risk of toxicity. A respiratory rate below 12/min is a
primary sign of magnesium toxicity and requires immediate intervention including
stopping the infusion. The nurse must also monitor for decreased deep tendon reflexes and
low urinary output as additional indicators of toxicity.
2. A laboring client’s electronic fetal monitor shows late decelerations. Which of the following
actions should the nurse take first?
A. Administer oxygen via nasal cannula at 2 L/min
B. Increase the rate of the IV maintenance fluids
,C. Perform a vaginal examination to check for cord prolapse
D. Turn the client to a side-lying position
Correct Answer: D
Late decelerations are caused by uteroplacental insufficiency and indicate fetal hypoxia.
Positioning the client on her side improves blood flow to the placenta by relieving pressure
on the inferior vena cava. After repositioning, the nurse should increase IV fluids,
administer oxygen via non-rebreather mask, and notify the provider if the pattern persists.
3. A nurse is caring for a client who is in the first stage of labor and has a prolapsed umbilical
cord. Which of the following positions should the nurse place the client in?
A. High-Fowler’s position
B. Lithotomy position
C. Left-lateral position
D. Knee-chest position
Correct Answer: D
A prolapsed umbilical cord is a medical emergency that requires immediate action to
relieve pressure on the cord. The knee-chest position or Trendelenburg position uses
gravity to shift the fetus away from the pelvis and the cord. The nurse should also use a
sterile gloved hand to apply upward pressure on the presenting part until delivery can
occur.
, 4. A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory
findings should the nurse report to the provider?
A. Nasal flaring and chest retractions
B. Acrocyanosis of the hands and feet
C. Respiratory rate of 50 breaths per minute
D. Brief periods of apnea lasting 10 seconds
Correct Answer: A
Nasal flaring, grunting, and intercostal retractions are classic signs of respiratory distress
in a newborn. While acrocyanosis and short periods of apnea (less than 20 seconds) are
normal transitional findings, persistent signs of increased work of breathing require
intervention. The nurse must assess the infant’s oxygen saturation and maintain a patent
airway.
5. A client at 34 weeks of gestation presents to the emergency department with sudden, dark
red vaginal bleeding and a board-like, tender abdomen. The nurse should suspect which of
the following conditions?
A. Abruptio placentae
B. Placenta previa
C. Spontaneous abortion
D. Hydatidiform mole
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 2) | Ivy Tech
1. A nurse is monitoring a client receiving magnesium sulfate for preeclampsia. Which of the
following findings should the nurse report to the provider immediately?
A. Respiratory rate of 10/min
B. Urinary output of 40 mL/hr
C. Presence of 2+ deep tendon reflexes
D. Blood pressure of 148/96 mmHg
Correct Answer: A
Magnesium sulfate is a central nervous system depressant used to prevent seizures in
preeclampsia, but it carries a high risk of toxicity. A respiratory rate below 12/min is a
primary sign of magnesium toxicity and requires immediate intervention including
stopping the infusion. The nurse must also monitor for decreased deep tendon reflexes and
low urinary output as additional indicators of toxicity.
2. A laboring client’s electronic fetal monitor shows late decelerations. Which of the following
actions should the nurse take first?
A. Administer oxygen via nasal cannula at 2 L/min
B. Increase the rate of the IV maintenance fluids
,C. Perform a vaginal examination to check for cord prolapse
D. Turn the client to a side-lying position
Correct Answer: D
Late decelerations are caused by uteroplacental insufficiency and indicate fetal hypoxia.
Positioning the client on her side improves blood flow to the placenta by relieving pressure
on the inferior vena cava. After repositioning, the nurse should increase IV fluids,
administer oxygen via non-rebreather mask, and notify the provider if the pattern persists.
3. A nurse is caring for a client who is in the first stage of labor and has a prolapsed umbilical
cord. Which of the following positions should the nurse place the client in?
A. High-Fowler’s position
B. Lithotomy position
C. Left-lateral position
D. Knee-chest position
Correct Answer: D
A prolapsed umbilical cord is a medical emergency that requires immediate action to
relieve pressure on the cord. The knee-chest position or Trendelenburg position uses
gravity to shift the fetus away from the pelvis and the cord. The nurse should also use a
sterile gloved hand to apply upward pressure on the presenting part until delivery can
occur.
, 4. A nurse is assessing a newborn 1 hour after birth. Which of the following respiratory
findings should the nurse report to the provider?
A. Nasal flaring and chest retractions
B. Acrocyanosis of the hands and feet
C. Respiratory rate of 50 breaths per minute
D. Brief periods of apnea lasting 10 seconds
Correct Answer: A
Nasal flaring, grunting, and intercostal retractions are classic signs of respiratory distress
in a newborn. While acrocyanosis and short periods of apnea (less than 20 seconds) are
normal transitional findings, persistent signs of increased work of breathing require
intervention. The nurse must assess the infant’s oxygen saturation and maintain a patent
airway.
5. A client at 34 weeks of gestation presents to the emergency department with sudden, dark
red vaginal bleeding and a board-like, tender abdomen. The nurse should suspect which of
the following conditions?
A. Abruptio placentae
B. Placenta previa
C. Spontaneous abortion
D. Hydatidiform mole
