NRSG 112 Exam 4 V2 | NRSG 112
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 4) | Ivy Tech
1. A nurse is caring for a client who is at 36 weeks gestation and has a prescription for a
nonstress test (NST). Which of the following instructions should the nurse provide to the
client?
A. You will need to remain NPO for 4 hours prior to the test.
B. You will press a button whenever you feel the baby move.
C. You should lie flat on your back during the procedure.
D. The test will take approximately 2 hours to complete.
Correct Answer: B
The nonstress test is a non-invasive procedure that monitors fetal heart rate in response
to fetal movement. The client is typically asked to press a button to mark when they feel
movement so the nurse can correlate it with heart rate accelerations. A reactive test is a
positive sign of fetal well-being, while a non-reactive test may require further follow-up
like a biophysical profile.
2. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis of the hands and feet
,B. Generalized petechiae over the trunk
C. Milia on the bridge of the nose
D. Vernix caseosa in the skin folds
Correct Answer: B
Generalized petechiae can indicate a clotting factor deficiency or infection and must be
reported immediately to the provider. Acrocyanosis is a normal finding in the first 24 to 48
hours of life due to poor peripheral circulation. Milia and vernix caseosa are expected
findings in a healthy newborn and do not require medical intervention.
3. A nurse is providing teaching to a parent of a child who has a new diagnosis of Type 1
Diabetes Mellitus. Which of the following should be included in the teaching plan?
A. Administer glucagon for severe hypoglycemic episodes.
B. Restrict exercise to prevent hypoglycemia.
C. Decrease fluid intake when the child is sick.
D. Monitor blood glucose levels once a week.
E. Increase sugar intake before bedtime to prevent overnight spikes.
Correct Answer: A
Glucagon is used as an emergency treatment for severe hypoglycemia when the child is
unable to take oral glucose. Education for parents must include the recognition of
hypoglycemia symptoms such as shakiness, sweating, and confusion. Consistent blood
,glucose monitoring and maintaining activity levels with appropriate snack adjustments are
also vital components of pediatric diabetes management.
4. A nurse is assessing a client in the fourth stage of labor. The nurse notes that the fundus is
firm, deviated to the right, and two fingerbreadths above the umbilicus. Which of the
following actions should the nurse take?
A. Massage the fundus vigorously.
B. Place the client in a Trendelenburg position.
C. Administer oxytocin as prescribed.
D. Assist the client to void.
Correct Answer: D
A fundus that is displaced to the right and elevated indicates a distended bladder, which
can interfere with uterine contractions and lead to hemorrhage. Assisting the client to
empty their bladder will allow the uterus to return to the midline and contract effectively.
The nurse should reassess the fundus position and firmness after the client has voided to
ensure stability.
5. A 10-year-old child is admitted with a suspected diagnosis of acute appendicitis. Which of
the following clinical manifestations should the nurse expect to observe?
A. Pain in the left lower quadrant
B. Bradycardia
C. Increased appetite
, D. Rebound tenderness at McBurney’s point
E. Hypotension
F. Steatorrhea
Correct Answer: D
Rebound tenderness at McBurney’s point, located halfway between the umbilicus and the
right iliac crest, is a classic sign of appendicitis. Other common symptoms include
periumbilical pain that migrates to the right lower quadrant, fever, and nausea. If the pain
suddenly disappears, it may indicate a ruptured appendix, which is a surgical emergency.
6. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings indicates magnesium sulfate toxicity?
A. Increased urine output
B. Respiratory rate of 18/min
C. Absence of deep tendon reflexes
D. Hyperreflexia
Correct Answer: C
Magnesium sulfate acts as a CNS depressant; therefore, the loss of deep tendon reflexes is
one of the earliest signs of toxicity. The nurse must also monitor for a respiratory rate
below 12/min and a significant decrease in urinary output. Calcium gluconate is the
standard antidote and should be readily available at the bedside during infusion.
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 4) | Ivy Tech
1. A nurse is caring for a client who is at 36 weeks gestation and has a prescription for a
nonstress test (NST). Which of the following instructions should the nurse provide to the
client?
A. You will need to remain NPO for 4 hours prior to the test.
B. You will press a button whenever you feel the baby move.
C. You should lie flat on your back during the procedure.
D. The test will take approximately 2 hours to complete.
Correct Answer: B
The nonstress test is a non-invasive procedure that monitors fetal heart rate in response
to fetal movement. The client is typically asked to press a button to mark when they feel
movement so the nurse can correlate it with heart rate accelerations. A reactive test is a
positive sign of fetal well-being, while a non-reactive test may require further follow-up
like a biophysical profile.
2. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis of the hands and feet
,B. Generalized petechiae over the trunk
C. Milia on the bridge of the nose
D. Vernix caseosa in the skin folds
Correct Answer: B
Generalized petechiae can indicate a clotting factor deficiency or infection and must be
reported immediately to the provider. Acrocyanosis is a normal finding in the first 24 to 48
hours of life due to poor peripheral circulation. Milia and vernix caseosa are expected
findings in a healthy newborn and do not require medical intervention.
3. A nurse is providing teaching to a parent of a child who has a new diagnosis of Type 1
Diabetes Mellitus. Which of the following should be included in the teaching plan?
A. Administer glucagon for severe hypoglycemic episodes.
B. Restrict exercise to prevent hypoglycemia.
C. Decrease fluid intake when the child is sick.
D. Monitor blood glucose levels once a week.
E. Increase sugar intake before bedtime to prevent overnight spikes.
Correct Answer: A
Glucagon is used as an emergency treatment for severe hypoglycemia when the child is
unable to take oral glucose. Education for parents must include the recognition of
hypoglycemia symptoms such as shakiness, sweating, and confusion. Consistent blood
,glucose monitoring and maintaining activity levels with appropriate snack adjustments are
also vital components of pediatric diabetes management.
4. A nurse is assessing a client in the fourth stage of labor. The nurse notes that the fundus is
firm, deviated to the right, and two fingerbreadths above the umbilicus. Which of the
following actions should the nurse take?
A. Massage the fundus vigorously.
B. Place the client in a Trendelenburg position.
C. Administer oxytocin as prescribed.
D. Assist the client to void.
Correct Answer: D
A fundus that is displaced to the right and elevated indicates a distended bladder, which
can interfere with uterine contractions and lead to hemorrhage. Assisting the client to
empty their bladder will allow the uterus to return to the midline and contract effectively.
The nurse should reassess the fundus position and firmness after the client has voided to
ensure stability.
5. A 10-year-old child is admitted with a suspected diagnosis of acute appendicitis. Which of
the following clinical manifestations should the nurse expect to observe?
A. Pain in the left lower quadrant
B. Bradycardia
C. Increased appetite
, D. Rebound tenderness at McBurney’s point
E. Hypotension
F. Steatorrhea
Correct Answer: D
Rebound tenderness at McBurney’s point, located halfway between the umbilicus and the
right iliac crest, is a classic sign of appendicitis. Other common symptoms include
periumbilical pain that migrates to the right lower quadrant, fever, and nausea. If the pain
suddenly disappears, it may indicate a ruptured appendix, which is a surgical emergency.
6. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of
the following findings indicates magnesium sulfate toxicity?
A. Increased urine output
B. Respiratory rate of 18/min
C. Absence of deep tendon reflexes
D. Hyperreflexia
Correct Answer: C
Magnesium sulfate acts as a CNS depressant; therefore, the loss of deep tendon reflexes is
one of the earliest signs of toxicity. The nurse must also monitor for a respiratory rate
below 12/min and a significant decrease in urinary output. Calcium gluconate is the
standard antidote and should be readily available at the bedside during infusion.
