NRSG 112 Final Exam V1 | NRSG 112
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Final Exam) | Ivy
Tech
1. A nurse is caring for a client in the first stage of labor and notes that the fetal heart rate
monitoring shows late decelerations. What is the priority nursing intervention?
A. Increase the rate of the oxytocin infusion
B. B Position the client on her left side
C. Perform a vaginal exam to check for cord prolapse
D. Administer oxygen via a simple face mask at 2 L/min
Correct Answer: B
Late decelerations are indicative of uteroplacental insufficiency, which requires
immediate intervention to improve fetal oxygenation. Positioning the client on her left side
helps displace the uterus from the inferior vena cava and improves blood flow to the
placenta. The nurse should also discontinue oxytocin if it is being administered and
increase IV fluids as part of the intrauterine resuscitation protocol.
2. A 24-hour-old neonate has a total serum bilirubin level of 12 mg/dL. Which of the following
is the most appropriate nursing action?
A. Continue to monitor and retest in 24 hours
,B. B Encourage frequent breastfeeding every 2 to 3 hours
C. Prepare the infant for an immediate exchange transfusion
D. Switch the infant from breast milk to sterile water for 12 hours
Correct Answer: B
Frequent breastfeeding helps stimulate the gastrocolic reflex and promotes the passage of
meconium, which contains large amounts of bilirubin. Reducing the enterohepatic
circulation through frequent stooling is a primary method for lowering bilirubin levels in
the newborn. A level of 12 mg/dL at 24 hours requires close follow-up and increased intake
rather than immediate invasive procedures like exchange transfusion.
3. A nurse is assessing a child with suspected epiglottitis. Which of the following clinical
manifestations should the nurse expect to find?
A. A Drooling, agitation, and absence of cough
B. Barking cough, afebrile, and stridor
C. Low-grade fever, runny nose, and wheezing
D. Severe sore throat, high fever, and productive cough
Correct Answer: A
Epiglottitis is a medical emergency characterized by the ‘four Ds’: drooling, dysphagia,
dysphonia, and distressed inspiratory efforts. The absence of a cough is a classic sign that
helps differentiate it from laryngotracheobronchitis (croup). Nurses must avoid any
, attempt to visualize the throat with a tongue blade as this can trigger a complete airway
obstruction.
4. Which of the following activities is most appropriate for a 4-year-old child according to
Piaget’s stages of cognitive development?
A. Solving abstract mathematical equations
B. B Engaging in symbolic play with a dollhouse
C. Understanding the principle of conservation of mass
D. Exploring the environment through oral sensations
Correct Answer: B
A 4-year-old is in the preoperational stage of cognitive development, which is
characterized by symbolic thinking and egocentrism. Symbolic play, such as pretending a
doll is a real person, is a hallmark of this stage. Children at this age do not yet have the
capacity for conservation or abstract logic, which develop in later stages.
5. A nurse is reviewing the lab results for a client at 32 weeks gestation diagnosed with
preeclampsia. Which of the following findings should be reported to the provider
immediately?
A. Platelet count of 150,000/mm3
B. Uric acid level of 5.0 mg/dL
C. C Creatinine level of 1.8 mg/dL
Maternal-Child Nursing | Actual Q&A with
Rationale (NRSG112 Final Exam) | Ivy
Tech
1. A nurse is caring for a client in the first stage of labor and notes that the fetal heart rate
monitoring shows late decelerations. What is the priority nursing intervention?
A. Increase the rate of the oxytocin infusion
B. B Position the client on her left side
C. Perform a vaginal exam to check for cord prolapse
D. Administer oxygen via a simple face mask at 2 L/min
Correct Answer: B
Late decelerations are indicative of uteroplacental insufficiency, which requires
immediate intervention to improve fetal oxygenation. Positioning the client on her left side
helps displace the uterus from the inferior vena cava and improves blood flow to the
placenta. The nurse should also discontinue oxytocin if it is being administered and
increase IV fluids as part of the intrauterine resuscitation protocol.
2. A 24-hour-old neonate has a total serum bilirubin level of 12 mg/dL. Which of the following
is the most appropriate nursing action?
A. Continue to monitor and retest in 24 hours
,B. B Encourage frequent breastfeeding every 2 to 3 hours
C. Prepare the infant for an immediate exchange transfusion
D. Switch the infant from breast milk to sterile water for 12 hours
Correct Answer: B
Frequent breastfeeding helps stimulate the gastrocolic reflex and promotes the passage of
meconium, which contains large amounts of bilirubin. Reducing the enterohepatic
circulation through frequent stooling is a primary method for lowering bilirubin levels in
the newborn. A level of 12 mg/dL at 24 hours requires close follow-up and increased intake
rather than immediate invasive procedures like exchange transfusion.
3. A nurse is assessing a child with suspected epiglottitis. Which of the following clinical
manifestations should the nurse expect to find?
A. A Drooling, agitation, and absence of cough
B. Barking cough, afebrile, and stridor
C. Low-grade fever, runny nose, and wheezing
D. Severe sore throat, high fever, and productive cough
Correct Answer: A
Epiglottitis is a medical emergency characterized by the ‘four Ds’: drooling, dysphagia,
dysphonia, and distressed inspiratory efforts. The absence of a cough is a classic sign that
helps differentiate it from laryngotracheobronchitis (croup). Nurses must avoid any
, attempt to visualize the throat with a tongue blade as this can trigger a complete airway
obstruction.
4. Which of the following activities is most appropriate for a 4-year-old child according to
Piaget’s stages of cognitive development?
A. Solving abstract mathematical equations
B. B Engaging in symbolic play with a dollhouse
C. Understanding the principle of conservation of mass
D. Exploring the environment through oral sensations
Correct Answer: B
A 4-year-old is in the preoperational stage of cognitive development, which is
characterized by symbolic thinking and egocentrism. Symbolic play, such as pretending a
doll is a real person, is a hallmark of this stage. Children at this age do not yet have the
capacity for conservation or abstract logic, which develop in later stages.
5. A nurse is reviewing the lab results for a client at 32 weeks gestation diagnosed with
preeclampsia. Which of the following findings should be reported to the provider
immediately?
A. Platelet count of 150,000/mm3
B. Uric acid level of 5.0 mg/dL
C. C Creatinine level of 1.8 mg/dL
