NRSG 112 Exam 3 V2 | NRSG 112 Maternal-Child
Nursing | Actual Q&A with Rationale (NRSG112
Exam 3) | Ivy Tech
1. A nurse is caring for a client who is 4 hours postpartum and has a saturated perineal pad in
15 minutes. Which action should the nurse take first?
A. Check the client’s blood pressure.
B. Administer oxytocin IV bolus.
C. Massage the client’s fundus.
D. Notify the provider immediately.
Correct Answer: C
Explanation: The first action for a postpartum client with excessive bleeding is to massage
the fundus to promote uterine contraction and stop hemorrhage. Excessive bleeding within
15 minutes is a primary sign of uterine atony. This immediate physical intervention is
prioritized before pharmacological or systemic assessments.
2. A nurse is preparing to administer erythromycin ophthalmic ointment to a newborn. Which
of the following techniques should the nurse use?
A. Apply the ointment from the outer canthus to the inner canthus.
B. Apply a thin ribbon of ointment into the lower conjunctival sac.
C. Apply a thin ribbon of ointment along the upper eyelid.
,D. Flush the eyes with sterile water before application.
Correct Answer: B
Explanation: Erythromycin ointment is applied to the lower conjunctival sac to prevent
ophthalmia neonatorum. The nurse should move from the inner to the outer canthus
during application. This procedure is mandatory by law in many regions to prevent
blindness from gonorrhea or chlamydia.
3. A nurse is assessing a client in the active stage of labor. The fetal heart rate (FHR) monitor
shows late decelerations. Which of the following is the priority intervention?
A. Increase the IV fluid rate.
B. Turn the client to a side-lying position.
C. Apply oxygen via nasal cannula.
D. Perform a vaginal exam.
E. Discontinue the oxytocin infusion.
Correct Answer: B
Explanation: Late decelerations indicate uteroplacental insufficiency, which can be life-
threatening for the fetus. Repositioning the mother to a side-lying position is the first step
to improve blood flow to the placenta. This nursing intervention aims to relieve pressure
on the vena cava and optimize oxygen delivery to the fetus.
, 4. A nurse is teaching a new mother about breastfeeding. Which of the following statements
indicates an understanding of the teaching?
A. I should feed my baby every 4 hours regardless of hunger cues.
B. I will wake my baby up if they sleep longer than 5 hours at night.
C. I will give my baby water between feedings if it is hot outside.
D. I will know my baby is getting enough milk if they have 6 to 8 wet diapers a day.
Correct Answer: D
Explanation: Adequate hydration and intake in a breastfed newborn are best monitored
by the number of wet diapers, typically 6 to 8 per 24 hours after the first week. Newborns
should not be given water as it can lead to hyponatremia and calorie displacement. Feeding
should be based on cues rather than a strict schedule to ensure supply meets demand.
5. A nurse is assessing a newborn at 1 minute after birth and finds the following: heart rate
110/min, slow/weak cry, some flexion of extremities, grimace when stimulated, and body
pink with blue extremities. What is the Apgar score?
A. 5
B. 9
C. 7
D. 8
E. 4
Nursing | Actual Q&A with Rationale (NRSG112
Exam 3) | Ivy Tech
1. A nurse is caring for a client who is 4 hours postpartum and has a saturated perineal pad in
15 minutes. Which action should the nurse take first?
A. Check the client’s blood pressure.
B. Administer oxytocin IV bolus.
C. Massage the client’s fundus.
D. Notify the provider immediately.
Correct Answer: C
Explanation: The first action for a postpartum client with excessive bleeding is to massage
the fundus to promote uterine contraction and stop hemorrhage. Excessive bleeding within
15 minutes is a primary sign of uterine atony. This immediate physical intervention is
prioritized before pharmacological or systemic assessments.
2. A nurse is preparing to administer erythromycin ophthalmic ointment to a newborn. Which
of the following techniques should the nurse use?
A. Apply the ointment from the outer canthus to the inner canthus.
B. Apply a thin ribbon of ointment into the lower conjunctival sac.
C. Apply a thin ribbon of ointment along the upper eyelid.
,D. Flush the eyes with sterile water before application.
Correct Answer: B
Explanation: Erythromycin ointment is applied to the lower conjunctival sac to prevent
ophthalmia neonatorum. The nurse should move from the inner to the outer canthus
during application. This procedure is mandatory by law in many regions to prevent
blindness from gonorrhea or chlamydia.
3. A nurse is assessing a client in the active stage of labor. The fetal heart rate (FHR) monitor
shows late decelerations. Which of the following is the priority intervention?
A. Increase the IV fluid rate.
B. Turn the client to a side-lying position.
C. Apply oxygen via nasal cannula.
D. Perform a vaginal exam.
E. Discontinue the oxytocin infusion.
Correct Answer: B
Explanation: Late decelerations indicate uteroplacental insufficiency, which can be life-
threatening for the fetus. Repositioning the mother to a side-lying position is the first step
to improve blood flow to the placenta. This nursing intervention aims to relieve pressure
on the vena cava and optimize oxygen delivery to the fetus.
, 4. A nurse is teaching a new mother about breastfeeding. Which of the following statements
indicates an understanding of the teaching?
A. I should feed my baby every 4 hours regardless of hunger cues.
B. I will wake my baby up if they sleep longer than 5 hours at night.
C. I will give my baby water between feedings if it is hot outside.
D. I will know my baby is getting enough milk if they have 6 to 8 wet diapers a day.
Correct Answer: D
Explanation: Adequate hydration and intake in a breastfed newborn are best monitored
by the number of wet diapers, typically 6 to 8 per 24 hours after the first week. Newborns
should not be given water as it can lead to hyponatremia and calorie displacement. Feeding
should be based on cues rather than a strict schedule to ensure supply meets demand.
5. A nurse is assessing a newborn at 1 minute after birth and finds the following: heart rate
110/min, slow/weak cry, some flexion of extremities, grimace when stimulated, and body
pink with blue extremities. What is the Apgar score?
A. 5
B. 9
C. 7
D. 8
E. 4
