NRSG 112 Exam 3 V3 | NRSG 112 Maternal-Child
Nursing | Actual Q&A with Rationale (NRSG112
Exam 3) | Ivy Tech
1. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. Milia across the bridge of the nose
C. Heart rate of 145 beats per minute
D. Generalized petechiae over the body
Correct Answer: D
Explanation: Generalized petechiae can indicate a systemic infection or a clotting disorder
in the newborn and must be reported immediately. Acrocyanosis is a normal finding in the
first 24 to 48 hours of life due to poor peripheral circulation. Milia are common sebaceous
gland secretions that disappear spontaneously, and a heart rate of 145 is within the
expected range of 110 to 160.
2. A nurse is caring for a client who is 4 hours postpartum and reports feeling a sudden gush
of vaginal blood. Upon assessment, the nurse finds the fundus is boggy and deviated to the
right. Which of the following actions should the nurse take first?
A. Massage the fundus until firm
B. Increase the IV oxytocin infusion rate
,C. Assist the client to the bathroom to void
D. Notify the primary care provider
Correct Answer: C
Explanation: A fundus that is boggy and deviated to the right typically indicates a
distended bladder, which prevents the uterus from contracting effectively. Assisting the
client to void is the priority action to allow the uterus to return to the midline and contract.
While fundal massage is important for bogginess, the deviation suggests bladder distension
is the primary cause that must be addressed first.
3. A nurse is preparing to administer Vitamin K (Phytonadione) to a newborn. The parents ask
why their baby needs this injection. Which of the following responses should the nurse
provide?
A. It helps to stimulate the production of red blood cells in the bone marrow.
B. It provides the newborn with passive immunity against common childhood illnesses.
C. It assists in the conjugation of bilirubin to prevent neonatal jaundice.
D. It is necessary because newborns lack the intestinal flora to produce this vitamin, which
is needed for clotting.
E. It promotes the absorption of calcium for healthy bone development.
Correct Answer: D
,Explanation: Newborns are born with a sterile gut and lack the bacteria necessary to
synthesize Vitamin K, which is a vital component for the synthesis of clotting factors. This
deficiency puts the infant at risk for Vitamin K Deficiency Bleeding (VKDB) during the first
week of life. The injection is administered intramuscularly in the vastus lateralis shortly
after birth to prevent hemorrhagic disease.
4. A nurse is teaching the parent of a 6-month-old infant about the introduction of solid
foods. Which of the following instructions should the nurse include?
A. Start with yellow vegetables before introducing green vegetables.
B. Mix fruit juice with cereal to increase vitamin C intake.
C. Introduce honey to the diet to provide natural sweetness.
D. Introduce new foods one at a time over a 5 to 7 day period.
Correct Answer: D
Explanation: Introducing new foods one at a time allows the parent to identify potential
food allergies or intolerances. If a reaction occurs, the specific food responsible can be
easily determined. Iron-fortified rice cereal is typically the first solid food introduced due
to its low allergenic potential and the infant’s need for iron at this age.
5. A nurse is assessing a client who is 2 days postpartum and breastfeeding. The client reports
nipple soreness. Which of the following interventions should the nurse recommend?
A. Apply a cold compress to the nipples after each feeding.
B. Apply a small amount of expressed colostrum to the nipples.
, C. Wash the nipples with soap and water twice daily.
D. Use a plastic-lined breast pad to keep the nipples dry.
Correct Answer: B
Explanation: Expressed colostrum or breast milk has bacteriostatic properties and can
help heal sore or cracked nipples. The nurse should also assess the infant’s latch and
positioning, as poor latch is the most common cause of nipple trauma. Clients should avoid
soap on the nipples because it can cause excessive dryness and further irritation.
6. A nurse is providing teaching to a parent of a child who has pediculosis capitis (head lice).
Which of the following instructions should the nurse include?
A. Boil all brushes and combs for 10 minutes.
B. Dry clean all non-washable items.
C. Seal items that cannot be washed in a plastic bag for 14 days.
D. Apply mayonnaise to the hair and leave it overnight.
E. Use a fine-toothed nit comb to remove nits from the hair shaft.
F. Shave the child’s head to prevent recurrence.
Correct Answer: E
Explanation: Manual removal of nits with a fine-toothed comb is an essential part of
treatment for head lice to prevent re-infestation. While pediculicides kill the active lice, the
Nursing | Actual Q&A with Rationale (NRSG112
Exam 3) | Ivy Tech
1. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis of the hands and feet
B. Milia across the bridge of the nose
C. Heart rate of 145 beats per minute
D. Generalized petechiae over the body
Correct Answer: D
Explanation: Generalized petechiae can indicate a systemic infection or a clotting disorder
in the newborn and must be reported immediately. Acrocyanosis is a normal finding in the
first 24 to 48 hours of life due to poor peripheral circulation. Milia are common sebaceous
gland secretions that disappear spontaneously, and a heart rate of 145 is within the
expected range of 110 to 160.
2. A nurse is caring for a client who is 4 hours postpartum and reports feeling a sudden gush
of vaginal blood. Upon assessment, the nurse finds the fundus is boggy and deviated to the
right. Which of the following actions should the nurse take first?
A. Massage the fundus until firm
B. Increase the IV oxytocin infusion rate
,C. Assist the client to the bathroom to void
D. Notify the primary care provider
Correct Answer: C
Explanation: A fundus that is boggy and deviated to the right typically indicates a
distended bladder, which prevents the uterus from contracting effectively. Assisting the
client to void is the priority action to allow the uterus to return to the midline and contract.
While fundal massage is important for bogginess, the deviation suggests bladder distension
is the primary cause that must be addressed first.
3. A nurse is preparing to administer Vitamin K (Phytonadione) to a newborn. The parents ask
why their baby needs this injection. Which of the following responses should the nurse
provide?
A. It helps to stimulate the production of red blood cells in the bone marrow.
B. It provides the newborn with passive immunity against common childhood illnesses.
C. It assists in the conjugation of bilirubin to prevent neonatal jaundice.
D. It is necessary because newborns lack the intestinal flora to produce this vitamin, which
is needed for clotting.
E. It promotes the absorption of calcium for healthy bone development.
Correct Answer: D
,Explanation: Newborns are born with a sterile gut and lack the bacteria necessary to
synthesize Vitamin K, which is a vital component for the synthesis of clotting factors. This
deficiency puts the infant at risk for Vitamin K Deficiency Bleeding (VKDB) during the first
week of life. The injection is administered intramuscularly in the vastus lateralis shortly
after birth to prevent hemorrhagic disease.
4. A nurse is teaching the parent of a 6-month-old infant about the introduction of solid
foods. Which of the following instructions should the nurse include?
A. Start with yellow vegetables before introducing green vegetables.
B. Mix fruit juice with cereal to increase vitamin C intake.
C. Introduce honey to the diet to provide natural sweetness.
D. Introduce new foods one at a time over a 5 to 7 day period.
Correct Answer: D
Explanation: Introducing new foods one at a time allows the parent to identify potential
food allergies or intolerances. If a reaction occurs, the specific food responsible can be
easily determined. Iron-fortified rice cereal is typically the first solid food introduced due
to its low allergenic potential and the infant’s need for iron at this age.
5. A nurse is assessing a client who is 2 days postpartum and breastfeeding. The client reports
nipple soreness. Which of the following interventions should the nurse recommend?
A. Apply a cold compress to the nipples after each feeding.
B. Apply a small amount of expressed colostrum to the nipples.
, C. Wash the nipples with soap and water twice daily.
D. Use a plastic-lined breast pad to keep the nipples dry.
Correct Answer: B
Explanation: Expressed colostrum or breast milk has bacteriostatic properties and can
help heal sore or cracked nipples. The nurse should also assess the infant’s latch and
positioning, as poor latch is the most common cause of nipple trauma. Clients should avoid
soap on the nipples because it can cause excessive dryness and further irritation.
6. A nurse is providing teaching to a parent of a child who has pediculosis capitis (head lice).
Which of the following instructions should the nurse include?
A. Boil all brushes and combs for 10 minutes.
B. Dry clean all non-washable items.
C. Seal items that cannot be washed in a plastic bag for 14 days.
D. Apply mayonnaise to the hair and leave it overnight.
E. Use a fine-toothed nit comb to remove nits from the hair shaft.
F. Shave the child’s head to prevent recurrence.
Correct Answer: E
Explanation: Manual removal of nits with a fine-toothed comb is an essential part of
treatment for head lice to prevent re-infestation. While pediculicides kill the active lice, the
