NRSG 112 Final Exam V2 | NRSG 112 Maternal-
Child Nursing | Actual Q&A with Rationale
(NRSG112 Final Exam) | Ivy Tech
1. A nurse is assessing a client at 34 weeks of gestation who has been diagnosed with severe
preeclampsia. Which of the following assessment findings should the nurse prioritize and
report to the provider immediately?
A. 1+ pitting edema in the lower extremities
B. Blood pressure of 152/98 mm Hg
C. Epigastric pain and persistent frontal headache
D. Deep tendon reflexes of 2+ bilaterally
E. Weight gain of 1.1 kg (2.4 lb) in one week
F. Urine output of 40 mL/hr
Correct Answer: C
Explanation: Epigastric pain and severe headaches are indicative of central nervous
system irritability and potential liver involvement, signaling a high risk for seizures
(eclampsia) or HELLP syndrome. While hypertension and edema are classic signs of
preeclampsia, they are expected findings in a stable patient; neurologic and hepatic signs
indicate worsening condition. The nurse must prioritize these symptoms to ensure
immediate medical intervention and prevent maternal or fetal harm.
,2. A nurse is evaluating the fetal heart rate (FHR) monitor tracing for a client in active labor.
The nurse notes a gradual slowing of the FHR that begins after the peak of the contraction
and returns to baseline only after the contraction has ended. Which of the following actions
should the nurse take first?
A. Increase the rate of the maintenance IV fluid infusion
B. Perform a sterile vaginal examination to check for cord prolapse
C. Administer oxygen at 8 to 10 L/min via nonrebreather face mask
D. Place the client in a lateral position
Correct Answer: D
Explanation: The description of the FHR indicates late decelerations, which are a sign of
uteroplacental insufficiency. The first priority in intrauterine resuscitation is to reposition
the client to their side to improve blood flow to the placenta and the fetus. Subsequent
actions include increasing IV fluids, administering oxygen, and notifying the provider if the
pattern persists.
3. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a weak cry with slow respirations, some flexion of the extremities, grimaces in
response to suctioning, and a pink body with blue extremities. What APGAR score should the
nurse assign?
A. 5
B. 7
,C. 6
D. 8
Correct Answer: C
Explanation: The APGAR score is calculated as follows: Heart rate >100 (2 points),
Respiratory effort weak/slow (1 point), Muscle tone some flexion (1 point), Reflex
irritability grimace (1 point), and Color pink body with blue extremities (1 point). Adding
these together (2+1+1+1+1) results in a total score of 6. A score between 4 and 6 indicates
that the newborn is having some difficulty adjusting to extrauterine life and requires close
monitoring.
4. A nurse is providing discharge teaching to a client who is 2 days postpartum. Which of the
following statements should the nurse include regarding lochia flow?
A. “Lochia rubra should be bright red and may contain small clots for the first few days.”
B. ‘Lochia serosa is a bright red discharge that lasts for about 3 days.’
C. ‘You should contact your doctor if your discharge turns from pink to white.’
D. ‘Lochia alba is the final stage and should be creamy white or yellow for up to 6 weeks.’
Correct Answer: A
Explanation: Lochia rubra consists of blood, decidual and trophoblastic debris, and is
expected for the first 1 to 3 days postpartum. Lochia serosa is the pinkish-brown discharge
that follows, and lochia alba is the yellow-to-white discharge that can last several weeks.
The nurse must teach the client that a reversal in the pattern (e.g., returning to bright red
, after it has turned pink) or a foul odor can indicate a complication like infection or late
postpartum hemorrhage.
5. A nurse is caring for a client who is receiving magnesium sulfate via continuous IV infusion
for the treatment of preeclampsia. Which of the following findings should the nurse identify
as a manifestation of magnesium toxicity?
A. Absence of deep tendon reflexes
B. Hyperreflexia of the patellar tendons
C. Respiratory rate of 16/min
D. Urine output of 50 mL/hr
E. Increased level of consciousness
Correct Answer: A
Explanation: Magnesium sulfate is a central nervous system depressant; therefore, the
loss of deep tendon reflexes is one of the earliest signs of toxicity. Other signs include
respiratory depression (rate less than 12/min), decreased level of consciousness, and
oliguria. If toxicity is suspected, the nurse must immediately stop the infusion and prepare
the antidote, calcium gluconate.
6. A nurse is assessing a child who has suspected intussusception. Which of the following
findings should the nurse expect?
A. Palpable olive-shaped mass in the epigastrium
B. Projectile vomiting after feeding
Child Nursing | Actual Q&A with Rationale
(NRSG112 Final Exam) | Ivy Tech
1. A nurse is assessing a client at 34 weeks of gestation who has been diagnosed with severe
preeclampsia. Which of the following assessment findings should the nurse prioritize and
report to the provider immediately?
A. 1+ pitting edema in the lower extremities
B. Blood pressure of 152/98 mm Hg
C. Epigastric pain and persistent frontal headache
D. Deep tendon reflexes of 2+ bilaterally
E. Weight gain of 1.1 kg (2.4 lb) in one week
F. Urine output of 40 mL/hr
Correct Answer: C
Explanation: Epigastric pain and severe headaches are indicative of central nervous
system irritability and potential liver involvement, signaling a high risk for seizures
(eclampsia) or HELLP syndrome. While hypertension and edema are classic signs of
preeclampsia, they are expected findings in a stable patient; neurologic and hepatic signs
indicate worsening condition. The nurse must prioritize these symptoms to ensure
immediate medical intervention and prevent maternal or fetal harm.
,2. A nurse is evaluating the fetal heart rate (FHR) monitor tracing for a client in active labor.
The nurse notes a gradual slowing of the FHR that begins after the peak of the contraction
and returns to baseline only after the contraction has ended. Which of the following actions
should the nurse take first?
A. Increase the rate of the maintenance IV fluid infusion
B. Perform a sterile vaginal examination to check for cord prolapse
C. Administer oxygen at 8 to 10 L/min via nonrebreather face mask
D. Place the client in a lateral position
Correct Answer: D
Explanation: The description of the FHR indicates late decelerations, which are a sign of
uteroplacental insufficiency. The first priority in intrauterine resuscitation is to reposition
the client to their side to improve blood flow to the placenta and the fetus. Subsequent
actions include increasing IV fluids, administering oxygen, and notifying the provider if the
pattern persists.
3. A nurse is assessing a newborn 1 minute after birth. The newborn has a heart rate of
110/min, a weak cry with slow respirations, some flexion of the extremities, grimaces in
response to suctioning, and a pink body with blue extremities. What APGAR score should the
nurse assign?
A. 5
B. 7
,C. 6
D. 8
Correct Answer: C
Explanation: The APGAR score is calculated as follows: Heart rate >100 (2 points),
Respiratory effort weak/slow (1 point), Muscle tone some flexion (1 point), Reflex
irritability grimace (1 point), and Color pink body with blue extremities (1 point). Adding
these together (2+1+1+1+1) results in a total score of 6. A score between 4 and 6 indicates
that the newborn is having some difficulty adjusting to extrauterine life and requires close
monitoring.
4. A nurse is providing discharge teaching to a client who is 2 days postpartum. Which of the
following statements should the nurse include regarding lochia flow?
A. “Lochia rubra should be bright red and may contain small clots for the first few days.”
B. ‘Lochia serosa is a bright red discharge that lasts for about 3 days.’
C. ‘You should contact your doctor if your discharge turns from pink to white.’
D. ‘Lochia alba is the final stage and should be creamy white or yellow for up to 6 weeks.’
Correct Answer: A
Explanation: Lochia rubra consists of blood, decidual and trophoblastic debris, and is
expected for the first 1 to 3 days postpartum. Lochia serosa is the pinkish-brown discharge
that follows, and lochia alba is the yellow-to-white discharge that can last several weeks.
The nurse must teach the client that a reversal in the pattern (e.g., returning to bright red
, after it has turned pink) or a foul odor can indicate a complication like infection or late
postpartum hemorrhage.
5. A nurse is caring for a client who is receiving magnesium sulfate via continuous IV infusion
for the treatment of preeclampsia. Which of the following findings should the nurse identify
as a manifestation of magnesium toxicity?
A. Absence of deep tendon reflexes
B. Hyperreflexia of the patellar tendons
C. Respiratory rate of 16/min
D. Urine output of 50 mL/hr
E. Increased level of consciousness
Correct Answer: A
Explanation: Magnesium sulfate is a central nervous system depressant; therefore, the
loss of deep tendon reflexes is one of the earliest signs of toxicity. Other signs include
respiratory depression (rate less than 12/min), decreased level of consciousness, and
oliguria. If toxicity is suspected, the nurse must immediately stop the infusion and prepare
the antidote, calcium gluconate.
6. A nurse is assessing a child who has suspected intussusception. Which of the following
findings should the nurse expect?
A. Palpable olive-shaped mass in the epigastrium
B. Projectile vomiting after feeding
