NRSG 112 Final Exam V3 | NRSG 112 Maternal-
Child Nursing | Actual Q&A with Rationale
(NRSG112 Final Exam) | Ivy Tech
1. A nurse is assessing a pregnant client who is at 30 weeks of gestation. Which of the
following findings should the nurse report to the provider as a potential sign of preeclampsia?
A. Dependent pitting edema of the ankles
B. Occasional Braxton Hicks contractions
C. Increased vaginal discharge
D. Generalized facial edema
Correct Answer: D
Explanation: Generalized edema, especially in the face and hands, is a clinical indicator of
preeclampsia due to fluid shifts. While dependent ankle edema is common in late
pregnancy, facial swelling is considered a pathological finding that warrants further
investigation of blood pressure and proteinuria. Early identification of these signs is vital
for preventing the progression to eclampsia.
2. A nurse is caring for a client in the active phase of labor. The fetal monitor displays a
pattern of variable decelerations. Which of the following actions should the nurse take first?
A. Change the client’s position
B. Increase the rate of the maintenance IV fluid
,C. Administer oxygen via a nonrebreather mask
D. Prepare for immediate vaginal delivery
Correct Answer: A
Explanation: Variable decelerations are typically caused by umbilical cord compression,
and changing the maternal position is the first intervention to relieve that pressure. This
action helps improve fetal oxygenation and blood flow by shifting the weight of the fetus.
The nurse must continue to monitor the fetal heart rate pattern to determine if the
intervention was successful in resolving the decelerations.
3. A nurse is teaching a parent of a 6-month-old infant about the introduction of solid foods.
Which of the following instructions should the nurse include?
A. Introduce iron-fortified rice cereal as the first solid food
B. Start with yellow vegetables to ensure Vitamin A intake
C. Introduce fruit juices before cereal
D. Mix solid foods in the baby’s bottle to encourage swallowing
Correct Answer: A
Explanation: Iron-fortified rice cereal is recommended as the first solid food because it is
easily digested and has a low risk of causing allergic reactions. By 6 months of age, an
infant’s iron stores from birth begin to deplete, making supplementation through diet
necessary. The transition to solids should be gradual and should not replace breast milk or
formula as the primary source of nutrition.
,4. A client at 34 weeks of gestation is diagnosed with placenta previa. The nurse should
identify that which of the following is a characteristic manifestation of this condition?
A. Board-like, tender abdomen
B. Severe lower back pain
C. Painless, bright red vaginal bleeding
D. Dark red vaginal bleeding with abdominal rigidity
Correct Answer: C
Explanation: Placenta previa is characterized by the painless onset of bright red vaginal
bleeding during the second or third trimester. This occurs because the placenta is
implanted in the lower uterine segment, and as the cervix begins to soften or dilate, the
placental attachment is disrupted. Unlike abruptio placentae, there is typically no
abdominal pain or rigidity associated with this condition.
5. A nurse is calculating the Naegele’s rule for a client whose last menstrual period (LMP)
began on May 10th. What is the estimated date of delivery (EDD)?
A. February 10th
B. February 17th
C. January 17th
D. March 17th
Correct Answer: B
, Explanation: Naegele’s rule is calculated by taking the first day of the last menstrual
period, subtracting three months, and adding seven days and one year. For an LMP of May
10, subtracting three months leads to February, and adding seven days leads to February
17. This rule assumes a standard 28-day cycle and is the most common method for
estimating the due date in clinical practice.
6. Which of the following interventions is the priority for a newborn immediately after birth?
A. Dry the newborn and maintain a warm environment
B. Apply erythromycin ophthalmic ointment
C. Administer Vitamin K injection
D. Obtain the first set of vital signs
Correct Answer: A
Explanation: Thermogenesis is limited in newborns, making them highly susceptible to
heat loss through evaporation, conduction, radiation, and convection. Drying the infant
immediately prevents cold stress, which can lead to metabolic acidosis and respiratory
distress. Maintaining a neutral thermal environment is the physiological priority before
secondary interventions like medications are administered.
7. A nurse is assessing a child with suspected epiglottitis. Which of the following actions
should the nurse avoid?
A. Allowing the child to sit in a tripod position
B. Using a tongue depressor to visualize the throat
Child Nursing | Actual Q&A with Rationale
(NRSG112 Final Exam) | Ivy Tech
1. A nurse is assessing a pregnant client who is at 30 weeks of gestation. Which of the
following findings should the nurse report to the provider as a potential sign of preeclampsia?
A. Dependent pitting edema of the ankles
B. Occasional Braxton Hicks contractions
C. Increased vaginal discharge
D. Generalized facial edema
Correct Answer: D
Explanation: Generalized edema, especially in the face and hands, is a clinical indicator of
preeclampsia due to fluid shifts. While dependent ankle edema is common in late
pregnancy, facial swelling is considered a pathological finding that warrants further
investigation of blood pressure and proteinuria. Early identification of these signs is vital
for preventing the progression to eclampsia.
2. A nurse is caring for a client in the active phase of labor. The fetal monitor displays a
pattern of variable decelerations. Which of the following actions should the nurse take first?
A. Change the client’s position
B. Increase the rate of the maintenance IV fluid
,C. Administer oxygen via a nonrebreather mask
D. Prepare for immediate vaginal delivery
Correct Answer: A
Explanation: Variable decelerations are typically caused by umbilical cord compression,
and changing the maternal position is the first intervention to relieve that pressure. This
action helps improve fetal oxygenation and blood flow by shifting the weight of the fetus.
The nurse must continue to monitor the fetal heart rate pattern to determine if the
intervention was successful in resolving the decelerations.
3. A nurse is teaching a parent of a 6-month-old infant about the introduction of solid foods.
Which of the following instructions should the nurse include?
A. Introduce iron-fortified rice cereal as the first solid food
B. Start with yellow vegetables to ensure Vitamin A intake
C. Introduce fruit juices before cereal
D. Mix solid foods in the baby’s bottle to encourage swallowing
Correct Answer: A
Explanation: Iron-fortified rice cereal is recommended as the first solid food because it is
easily digested and has a low risk of causing allergic reactions. By 6 months of age, an
infant’s iron stores from birth begin to deplete, making supplementation through diet
necessary. The transition to solids should be gradual and should not replace breast milk or
formula as the primary source of nutrition.
,4. A client at 34 weeks of gestation is diagnosed with placenta previa. The nurse should
identify that which of the following is a characteristic manifestation of this condition?
A. Board-like, tender abdomen
B. Severe lower back pain
C. Painless, bright red vaginal bleeding
D. Dark red vaginal bleeding with abdominal rigidity
Correct Answer: C
Explanation: Placenta previa is characterized by the painless onset of bright red vaginal
bleeding during the second or third trimester. This occurs because the placenta is
implanted in the lower uterine segment, and as the cervix begins to soften or dilate, the
placental attachment is disrupted. Unlike abruptio placentae, there is typically no
abdominal pain or rigidity associated with this condition.
5. A nurse is calculating the Naegele’s rule for a client whose last menstrual period (LMP)
began on May 10th. What is the estimated date of delivery (EDD)?
A. February 10th
B. February 17th
C. January 17th
D. March 17th
Correct Answer: B
, Explanation: Naegele’s rule is calculated by taking the first day of the last menstrual
period, subtracting three months, and adding seven days and one year. For an LMP of May
10, subtracting three months leads to February, and adding seven days leads to February
17. This rule assumes a standard 28-day cycle and is the most common method for
estimating the due date in clinical practice.
6. Which of the following interventions is the priority for a newborn immediately after birth?
A. Dry the newborn and maintain a warm environment
B. Apply erythromycin ophthalmic ointment
C. Administer Vitamin K injection
D. Obtain the first set of vital signs
Correct Answer: A
Explanation: Thermogenesis is limited in newborns, making them highly susceptible to
heat loss through evaporation, conduction, radiation, and convection. Drying the infant
immediately prevents cold stress, which can lead to metabolic acidosis and respiratory
distress. Maintaining a neutral thermal environment is the physiological priority before
secondary interventions like medications are administered.
7. A nurse is assessing a child with suspected epiglottitis. Which of the following actions
should the nurse avoid?
A. Allowing the child to sit in a tripod position
B. Using a tongue depressor to visualize the throat
