NRSG 112 Exam 2 V3 | NRSG 112 Maternal-Child
Nursing | Actual Q&A with Rationale (NRSG112
Exam 2) | Ivy Tech
1. A nurse is assessing a client at 32 weeks’ gestation who reports sudden, sharp, abdominal
pain and dark red vaginal bleeding. The nurse notes the client’s abdomen is rigid and board-
like. Which of the following conditions should the nurse suspect?
A. Placenta previa
B. Hydatidiform mole
C. Abruptio placentae
D. Incompetent cervix
E. Preterm labor
Correct Answer: C
Explanation: Abruptio placentae is characterized by the premature separation of the
placenta from the uterus, which causes sharp pain and a board-like abdomen due to
internal bleeding. Placenta previa typically presents with painless, bright red bleeding. This
situation is a medical emergency that requires immediate intervention to ensure maternal
and fetal safety.
,2. A nurse is caring for a client in labor who is receiving an oxytocin infusion. The nurse notes
a fetal heart rate pattern showing late decelerations. Which of the following actions should
the nurse take first?
A. Notify the primary healthcare provider
B. Administer oxygen via non-rebreather mask
C. Increase the intravenous fluid rate
D. Turn the client onto her left side
Correct Answer: D
Explanation: Late decelerations indicate uteroplacental insufficiency, which is a critical
concern for fetal oxygenation. Repositioning the client to the side-lying position is the
priority action to relieve pressure on the vena cava and improve blood flow to the placenta.
Following this, oxygen administration and discontinuing oxytocin would be appropriate
steps in the intrauterine resuscitation protocol.
3. A client at 35 weeks’ gestation is diagnosed with mild preeclampsia. Which of the following
findings should the nurse identify as a sign that the condition is progressing to severe
preeclampsia?
A. 1+ pedal edema
B. Urine output of 50 mL/hr
C. Blood pressure of 142/92 mmHg
D. Blurred vision or headache
,Correct Answer: D
Explanation: Neurological symptoms such as blurred vision, photophobia, or a persistent
headache are indicative of central nervous system irritability in preeclampsia. These
symptoms suggest the condition is worsening and may lead to eclampsia (seizures). The
nurse must monitor for these signs closely as they represent significant disease
progression compared to mild hypertension or edema.
4. A nurse is monitoring a client who is receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following findings requires the nurse to stop the infusion?
A. Respirations 14/min
B. Deep tendon reflexes 2+
C. Urinary output of 35 mL/hr
D. Absent patellar reflexes
Correct Answer: D
Explanation: Loss of deep tendon reflexes, such as the patellar reflex, is one of the earliest
signs of magnesium sulfate toxicity. Other signs include respiratory depression below 12
breaths per minute and significant oliguria. The nurse must stop the infusion immediately
and prepare to administer calcium gluconate, which is the antagonist for magnesium
sulfate.
, 5. A client is in the second stage of labor. Which of the following clinical manifestations
should the nurse expect to observe?
A. Cervical dilation from 4 to 7 cm
B. The urge to push with contractions
C. Expulsion of the placenta
D. Bloody show and rupture of membranes
Correct Answer: B
Explanation: The second stage of labor begins with complete cervical dilation (10 cm) and
ends with the birth of the newborn. During this stage, the client typically feels a strong
involuntary urge to push or bear down due to the Ferguson reflex. The expulsion of the
placenta occurs in the third stage, and cervical dilation to 7 cm occurs in the active phase of
the first stage.
6. A nurse is providing discharge teaching to a client who is postpartum and has a prescription
for Rho(D) immune globulin. Which of the following information should the nurse include?
A. It should be given to all mothers within 72 hr of delivery.
B. It provides permanent immunity against the Rh factor.
C. It is administered to Rh-negative mothers who have Rh-positive infants.
D. It is used to treat newborns who have hemolytic disease.
Correct Answer: C
Nursing | Actual Q&A with Rationale (NRSG112
Exam 2) | Ivy Tech
1. A nurse is assessing a client at 32 weeks’ gestation who reports sudden, sharp, abdominal
pain and dark red vaginal bleeding. The nurse notes the client’s abdomen is rigid and board-
like. Which of the following conditions should the nurse suspect?
A. Placenta previa
B. Hydatidiform mole
C. Abruptio placentae
D. Incompetent cervix
E. Preterm labor
Correct Answer: C
Explanation: Abruptio placentae is characterized by the premature separation of the
placenta from the uterus, which causes sharp pain and a board-like abdomen due to
internal bleeding. Placenta previa typically presents with painless, bright red bleeding. This
situation is a medical emergency that requires immediate intervention to ensure maternal
and fetal safety.
,2. A nurse is caring for a client in labor who is receiving an oxytocin infusion. The nurse notes
a fetal heart rate pattern showing late decelerations. Which of the following actions should
the nurse take first?
A. Notify the primary healthcare provider
B. Administer oxygen via non-rebreather mask
C. Increase the intravenous fluid rate
D. Turn the client onto her left side
Correct Answer: D
Explanation: Late decelerations indicate uteroplacental insufficiency, which is a critical
concern for fetal oxygenation. Repositioning the client to the side-lying position is the
priority action to relieve pressure on the vena cava and improve blood flow to the placenta.
Following this, oxygen administration and discontinuing oxytocin would be appropriate
steps in the intrauterine resuscitation protocol.
3. A client at 35 weeks’ gestation is diagnosed with mild preeclampsia. Which of the following
findings should the nurse identify as a sign that the condition is progressing to severe
preeclampsia?
A. 1+ pedal edema
B. Urine output of 50 mL/hr
C. Blood pressure of 142/92 mmHg
D. Blurred vision or headache
,Correct Answer: D
Explanation: Neurological symptoms such as blurred vision, photophobia, or a persistent
headache are indicative of central nervous system irritability in preeclampsia. These
symptoms suggest the condition is worsening and may lead to eclampsia (seizures). The
nurse must monitor for these signs closely as they represent significant disease
progression compared to mild hypertension or edema.
4. A nurse is monitoring a client who is receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following findings requires the nurse to stop the infusion?
A. Respirations 14/min
B. Deep tendon reflexes 2+
C. Urinary output of 35 mL/hr
D. Absent patellar reflexes
Correct Answer: D
Explanation: Loss of deep tendon reflexes, such as the patellar reflex, is one of the earliest
signs of magnesium sulfate toxicity. Other signs include respiratory depression below 12
breaths per minute and significant oliguria. The nurse must stop the infusion immediately
and prepare to administer calcium gluconate, which is the antagonist for magnesium
sulfate.
, 5. A client is in the second stage of labor. Which of the following clinical manifestations
should the nurse expect to observe?
A. Cervical dilation from 4 to 7 cm
B. The urge to push with contractions
C. Expulsion of the placenta
D. Bloody show and rupture of membranes
Correct Answer: B
Explanation: The second stage of labor begins with complete cervical dilation (10 cm) and
ends with the birth of the newborn. During this stage, the client typically feels a strong
involuntary urge to push or bear down due to the Ferguson reflex. The expulsion of the
placenta occurs in the third stage, and cervical dilation to 7 cm occurs in the active phase of
the first stage.
6. A nurse is providing discharge teaching to a client who is postpartum and has a prescription
for Rho(D) immune globulin. Which of the following information should the nurse include?
A. It should be given to all mothers within 72 hr of delivery.
B. It provides permanent immunity against the Rh factor.
C. It is administered to Rh-negative mothers who have Rh-positive infants.
D. It is used to treat newborns who have hemolytic disease.
Correct Answer: C
