NRSG 112 Exam 3 V1 | NRSG 112 Maternal-Child
Nursing | Actual Q&A with Rationale (NRSG112
Exam 3) | Ivy Tech
1. A nurse is assessing a postpartum client who is 4 hours following a vaginal delivery. The
nurse notes the fundus is firm, midline, and two fingerbreadths below the umbilicus, but the
client is experiencing a steady trickle of bright red blood. Which of the following should the
nurse suspect?
A. Uterine atony
B. Normal lochia rubra
C. Retained placental fragments
D. Cervical or vaginal laceration
E. Inversion of the uterus
Correct Answer: D
Explanation: A firm fundus with a steady trickle of blood is a classic sign of a laceration
rather than uterine atony. Uterine atony typically presents as a boggy or soft uterus. The
nurse must notify the provider immediately to facilitate repair of the laceration.
2. Which of the following findings in a newborn should the nurse report to the healthcare
provider immediately?
A. Acrocyanosis in the hands and feet
,B. Erythema toxicum on the trunk
C. Milia on the bridge of the nose
D. Nasal flaring and chest retractions
Correct Answer: D
Explanation: Nasal flaring and retractions are signs of respiratory distress in the neonate
and require immediate intervention. Acrocyanosis is a normal finding within the first 24 to
48 hours of life. Milia and erythema toxicum are common, benign skin conditions that do
not require emergency reporting.
3. A nurse is teaching a mother of a 2-month-old infant about Sudden Infant Death Syndrome
(SIDS) prevention. Which instruction should be included?
A. Place the infant in a side-lying position for sleep.
B. Keep the nursery temperature at 80 degrees Fahrenheit.
C. Place the infant on a firm mattress in a supine position.
D. Place soft pillows and bumper pads in the crib.
Correct Answer: C
Explanation: The ‘Back to Sleep’ campaign recommends the supine position on a firm
surface to reduce SIDS risk. Soft bedding, including pillows and bumpers, increases the risk
of suffocation. Maintaining a cool, comfortable environment is also recommended to
prevent overheating.
, 4. A nurse is caring for a 4-year-old child following a tonsillectomy. Which of the following is
the priority assessment finding?
A. Complaints of a sore throat
B. Refusal to drink orange juice
C. A low-grade fever of 100.2 F
D. Frequent swallowing or throat clearing
Correct Answer: D
Explanation: Frequent swallowing is a cardinal sign of postoperative bleeding in a patient
who has undergone a tonsillectomy. This occurs as the child swallows blood trickling down
the back of the throat. Immediate surgical evaluation is necessary if hemorrhage is
suspected.
5. A newborn has an Apgar score of 9 at one minute and 10 at five minutes. How should the
nurse interpret these scores?
A. The newborn is in severe distress.
B. The newborn requires immediate resuscitation.
C. The newborn is showing good adjustment to extrauterine life.
D. The newborn is having moderate difficulty adjusting.
Correct Answer: C
Nursing | Actual Q&A with Rationale (NRSG112
Exam 3) | Ivy Tech
1. A nurse is assessing a postpartum client who is 4 hours following a vaginal delivery. The
nurse notes the fundus is firm, midline, and two fingerbreadths below the umbilicus, but the
client is experiencing a steady trickle of bright red blood. Which of the following should the
nurse suspect?
A. Uterine atony
B. Normal lochia rubra
C. Retained placental fragments
D. Cervical or vaginal laceration
E. Inversion of the uterus
Correct Answer: D
Explanation: A firm fundus with a steady trickle of blood is a classic sign of a laceration
rather than uterine atony. Uterine atony typically presents as a boggy or soft uterus. The
nurse must notify the provider immediately to facilitate repair of the laceration.
2. Which of the following findings in a newborn should the nurse report to the healthcare
provider immediately?
A. Acrocyanosis in the hands and feet
,B. Erythema toxicum on the trunk
C. Milia on the bridge of the nose
D. Nasal flaring and chest retractions
Correct Answer: D
Explanation: Nasal flaring and retractions are signs of respiratory distress in the neonate
and require immediate intervention. Acrocyanosis is a normal finding within the first 24 to
48 hours of life. Milia and erythema toxicum are common, benign skin conditions that do
not require emergency reporting.
3. A nurse is teaching a mother of a 2-month-old infant about Sudden Infant Death Syndrome
(SIDS) prevention. Which instruction should be included?
A. Place the infant in a side-lying position for sleep.
B. Keep the nursery temperature at 80 degrees Fahrenheit.
C. Place the infant on a firm mattress in a supine position.
D. Place soft pillows and bumper pads in the crib.
Correct Answer: C
Explanation: The ‘Back to Sleep’ campaign recommends the supine position on a firm
surface to reduce SIDS risk. Soft bedding, including pillows and bumpers, increases the risk
of suffocation. Maintaining a cool, comfortable environment is also recommended to
prevent overheating.
, 4. A nurse is caring for a 4-year-old child following a tonsillectomy. Which of the following is
the priority assessment finding?
A. Complaints of a sore throat
B. Refusal to drink orange juice
C. A low-grade fever of 100.2 F
D. Frequent swallowing or throat clearing
Correct Answer: D
Explanation: Frequent swallowing is a cardinal sign of postoperative bleeding in a patient
who has undergone a tonsillectomy. This occurs as the child swallows blood trickling down
the back of the throat. Immediate surgical evaluation is necessary if hemorrhage is
suspected.
5. A newborn has an Apgar score of 9 at one minute and 10 at five minutes. How should the
nurse interpret these scores?
A. The newborn is in severe distress.
B. The newborn requires immediate resuscitation.
C. The newborn is showing good adjustment to extrauterine life.
D. The newborn is having moderate difficulty adjusting.
Correct Answer: C
