NRSG 112 Exam 4 V3 | NRSG 112
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 4) | Ivy Tech
1. A nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The
nurse notes the fundus is firm, 2 cm above the umbilicus, and deviated to the right. Which of
the following actions should the nurse take first?
A. Massage the fundus until it is firm.
B. Administer 10 units of oxytocin IM.
C. Notify the provider of a possible hemorrhage.
D. Assist the client to the bathroom to void.
Correct Answer: D
A fundus that is displaced to the right and above the umbilicus is a classic sign of bladder
distention. A full bladder prevents the uterus from contracting effectively, which increases
the risk of postpartum hemorrhage. Assisting the client to empty her bladder is the priority
nursing intervention to allow the fundus to return to the midline and a lower position.
2. A nurse is providing discharge teaching to the parents of a newborn who has just
undergone a Gomco circumcision. Which of the following instructions should the nurse
include?
A. Apply petroleum jelly to the glans with each diaper change.
,B. Apply the diaper tightly to provide pressure to the site.
C. Wash off the yellow crust that forms on the glans daily.
D. Cleanse the area with soap and water if it becomes soiled.
Correct Answer: A
Petroleum jelly should be applied to the glans to prevent the diaper from adhering to the
healing site. The yellow exudate that forms is a normal part of healing and should not be
washed off or removed. Diapers should be fastened loosely, and cleaning should be done
with warm water only until the site is healed.
3. A nurse is caring for a client who is 12 hours postpartum following a vaginal delivery.
Which of the following findings should the nurse report to the provider?
A. Uterine fundus at the level of the umbilicus
B. Foul-smelling lochia rubra
C. Urine output of 3,000 mL in 24 hours
D. Oral temperature of 37.8°C (100°F)
Correct Answer: B
Lochia rubra should have a fleshy odor similar to menstrual blood; a foul odor is indicative
of endometrial infection. A fundus at the umbilicus and diuresis of up to 3,000 mL are
normal findings in the early postpartum period. A slight temperature elevation within the
first 24 hours is also common due to dehydration during labor.
,4. Which of the following infants is at the highest risk for developing hyperbilirubinemia?
A. A newborn born at 39 weeks gestation
B. A newborn who is being formula fed every 4 hours
C. A newborn with a cephalhematoma
D. A newborn with a negative direct Coombs test
Correct Answer: C
A cephalhematoma involves a collection of blood between the skull and periosteum; as
these red blood cells break down, bilirubin levels rise. This increased breakdown of RBCs
puts the infant at a much higher risk for physiologic jaundice. Nursing care includes
monitoring bilirubin levels and assessing the infant’s skin color and sclera.
5. A nurse is evaluating the APGAR score of a newborn at 1 minute. The infant has a heart
rate of 110/min, a weak cry, some flexion of the extremities, grimacing when the soles are
flicked, and a completely pink body. What score should the nurse assign?
A. 7
B. 6
C. 8
D. 9
Correct Answer: A
, The score is calculated as follows: Heart rate (110) = 2; Respiratory effort (weak cry) = 1;
Muscle tone (some flexion) = 1; Reflex irritability (grimace) = 1; Color (completely pink) =
2. Adding these together (2+1+1+1+2) results in an APGAR score of 7. This score indicates
that the newborn is in stable condition but requires continued monitoring.
6. A toddler is admitted to the pediatric unit with a diagnosis of croup
(laryngotracheobronchitis). Which of the following assessment findings is the priority for the
nurse to report?
A. Barky cough
B. Hoarseness
C. Agitation and restlessness
D. Temperature of 38.0°C (100.4°F)
E. Inspiratory stridor at rest
Correct Answer: E
While a barky cough and hoarseness are expected signs of croup, inspiratory stridor at
rest indicates significant airway narrowing and impending respiratory failure. Agitation
and restlessness are also concerning as they indicate hypoxia, but stridor is the direct
physical indicator of airway obstruction. The nurse must prioritize airway patency and
prepare for potential interventions like racemic epinephrine.
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Exam 4) | Ivy Tech
1. A nurse is performing a postpartum assessment on a client who delivered 4 hours ago. The
nurse notes the fundus is firm, 2 cm above the umbilicus, and deviated to the right. Which of
the following actions should the nurse take first?
A. Massage the fundus until it is firm.
B. Administer 10 units of oxytocin IM.
C. Notify the provider of a possible hemorrhage.
D. Assist the client to the bathroom to void.
Correct Answer: D
A fundus that is displaced to the right and above the umbilicus is a classic sign of bladder
distention. A full bladder prevents the uterus from contracting effectively, which increases
the risk of postpartum hemorrhage. Assisting the client to empty her bladder is the priority
nursing intervention to allow the fundus to return to the midline and a lower position.
2. A nurse is providing discharge teaching to the parents of a newborn who has just
undergone a Gomco circumcision. Which of the following instructions should the nurse
include?
A. Apply petroleum jelly to the glans with each diaper change.
,B. Apply the diaper tightly to provide pressure to the site.
C. Wash off the yellow crust that forms on the glans daily.
D. Cleanse the area with soap and water if it becomes soiled.
Correct Answer: A
Petroleum jelly should be applied to the glans to prevent the diaper from adhering to the
healing site. The yellow exudate that forms is a normal part of healing and should not be
washed off or removed. Diapers should be fastened loosely, and cleaning should be done
with warm water only until the site is healed.
3. A nurse is caring for a client who is 12 hours postpartum following a vaginal delivery.
Which of the following findings should the nurse report to the provider?
A. Uterine fundus at the level of the umbilicus
B. Foul-smelling lochia rubra
C. Urine output of 3,000 mL in 24 hours
D. Oral temperature of 37.8°C (100°F)
Correct Answer: B
Lochia rubra should have a fleshy odor similar to menstrual blood; a foul odor is indicative
of endometrial infection. A fundus at the umbilicus and diuresis of up to 3,000 mL are
normal findings in the early postpartum period. A slight temperature elevation within the
first 24 hours is also common due to dehydration during labor.
,4. Which of the following infants is at the highest risk for developing hyperbilirubinemia?
A. A newborn born at 39 weeks gestation
B. A newborn who is being formula fed every 4 hours
C. A newborn with a cephalhematoma
D. A newborn with a negative direct Coombs test
Correct Answer: C
A cephalhematoma involves a collection of blood between the skull and periosteum; as
these red blood cells break down, bilirubin levels rise. This increased breakdown of RBCs
puts the infant at a much higher risk for physiologic jaundice. Nursing care includes
monitoring bilirubin levels and assessing the infant’s skin color and sclera.
5. A nurse is evaluating the APGAR score of a newborn at 1 minute. The infant has a heart
rate of 110/min, a weak cry, some flexion of the extremities, grimacing when the soles are
flicked, and a completely pink body. What score should the nurse assign?
A. 7
B. 6
C. 8
D. 9
Correct Answer: A
, The score is calculated as follows: Heart rate (110) = 2; Respiratory effort (weak cry) = 1;
Muscle tone (some flexion) = 1; Reflex irritability (grimace) = 1; Color (completely pink) =
2. Adding these together (2+1+1+1+2) results in an APGAR score of 7. This score indicates
that the newborn is in stable condition but requires continued monitoring.
6. A toddler is admitted to the pediatric unit with a diagnosis of croup
(laryngotracheobronchitis). Which of the following assessment findings is the priority for the
nurse to report?
A. Barky cough
B. Hoarseness
C. Agitation and restlessness
D. Temperature of 38.0°C (100.4°F)
E. Inspiratory stridor at rest
Correct Answer: E
While a barky cough and hoarseness are expected signs of croup, inspiratory stridor at
rest indicates significant airway narrowing and impending respiratory failure. Agitation
and restlessness are also concerning as they indicate hypoxia, but stridor is the direct
physical indicator of airway obstruction. The nurse must prioritize airway patency and
prepare for potential interventions like racemic epinephrine.
