NRSG 112 Exam 4 V1 | NRSG 112 Maternal-Child
Nursing | Actual Q&A with Rationale (NRSG112
Exam 4) | Ivy Tech
1. A nurse is assessing a newborn at 1 minute after birth. The infant has a heart rate of 110
bpm, a slow/irregular respiratory effort, some flexion of extremities, a grimace in response to
suctioning, and a pink body with blue extremities. What APGAR score should the nurse
assign?
A. 4
B. 5
C. 7
D. 6
E. 8
Correct Answer: D
Explanation: The infant receives 2 points for heart rate (>100), 1 point for respiratory
effort (slow/irregular), 1 point for muscle tone (some flexion), 1 point for reflex irritability
(grimace), and 1 point for color (acrocyanosis). Summing these points results in a total
score of 6. This scoring system is critical for evaluating the need for immediate
resuscitation in the delivery room.
,2. Which clinical manifestation should a nurse prioritize when assessing a 2-year-old child
suspected of having acute epiglottitis?
A. Low-grade fever and a barking cough
B. Drooling, agitation, and absence of spontaneous cough
C. Wheezing and intercostal retractions
D. Roughness in voice and purulent sputum
Correct Answer: B
Explanation: Acute epiglottitis is a medical emergency characterized by the ‘four Ds’:
drooling, dysphagia, dysphonia, and distressed inspiratory efforts. The absence of a
spontaneous cough is a hallmark sign that differentiates it from viral croup. The nurse must
avoid examining the throat with a tongue blade as this can trigger a complete airway
obstruction.
3. A postpartum client is experiencing heavy vaginal bleeding and a boggy uterus 2 hours
after delivery. Which medication should the nurse anticipate administering first?
A. Methylergonovine (Methergine)
B. Oxytocin (Pitocin)
C. Carboprost (Hemabate)
D. Misoprostol (Cytotec)
Correct Answer: B
, Explanation: Oxytocin is the first-line medication for managing postpartum hemorrhage
caused by uterine atony. It acts by stimulating uterine contractions to compress
intramyometrial blood vessels. Other medications like Methergine or Hemabate are
typically utilized if oxytocin is ineffective or contraindicated.
4. When assessing a 10-month-old infant for developmental milestones, which finding would
require further investigation by the nurse?
A. The infant can sit unsupported
B. The infant uses a pincer grasp
C. The infant exhibits stranger anxiety
D. The infant has not yet begun to crawl
Correct Answer: D
Explanation: While infants develop at different rates, most infants should be crawling or
creeping by 9 to 10 months of age. The inability to sit unsupported or a lack of vocalization
would be more significant, but crawling is a key gross motor milestone for this age bracket.
The nurse should perform a standardized screening tool to determine if the delay is
significant.
5. A nurse is teaching parents of a child with Cystic Fibrosis (CF) about nutritional
requirements. Which instruction is most important?
A. Administer pancreatic enzymes with every meal and snack
B. Provide a low-fat, low-calorie diet
Nursing | Actual Q&A with Rationale (NRSG112
Exam 4) | Ivy Tech
1. A nurse is assessing a newborn at 1 minute after birth. The infant has a heart rate of 110
bpm, a slow/irregular respiratory effort, some flexion of extremities, a grimace in response to
suctioning, and a pink body with blue extremities. What APGAR score should the nurse
assign?
A. 4
B. 5
C. 7
D. 6
E. 8
Correct Answer: D
Explanation: The infant receives 2 points for heart rate (>100), 1 point for respiratory
effort (slow/irregular), 1 point for muscle tone (some flexion), 1 point for reflex irritability
(grimace), and 1 point for color (acrocyanosis). Summing these points results in a total
score of 6. This scoring system is critical for evaluating the need for immediate
resuscitation in the delivery room.
,2. Which clinical manifestation should a nurse prioritize when assessing a 2-year-old child
suspected of having acute epiglottitis?
A. Low-grade fever and a barking cough
B. Drooling, agitation, and absence of spontaneous cough
C. Wheezing and intercostal retractions
D. Roughness in voice and purulent sputum
Correct Answer: B
Explanation: Acute epiglottitis is a medical emergency characterized by the ‘four Ds’:
drooling, dysphagia, dysphonia, and distressed inspiratory efforts. The absence of a
spontaneous cough is a hallmark sign that differentiates it from viral croup. The nurse must
avoid examining the throat with a tongue blade as this can trigger a complete airway
obstruction.
3. A postpartum client is experiencing heavy vaginal bleeding and a boggy uterus 2 hours
after delivery. Which medication should the nurse anticipate administering first?
A. Methylergonovine (Methergine)
B. Oxytocin (Pitocin)
C. Carboprost (Hemabate)
D. Misoprostol (Cytotec)
Correct Answer: B
, Explanation: Oxytocin is the first-line medication for managing postpartum hemorrhage
caused by uterine atony. It acts by stimulating uterine contractions to compress
intramyometrial blood vessels. Other medications like Methergine or Hemabate are
typically utilized if oxytocin is ineffective or contraindicated.
4. When assessing a 10-month-old infant for developmental milestones, which finding would
require further investigation by the nurse?
A. The infant can sit unsupported
B. The infant uses a pincer grasp
C. The infant exhibits stranger anxiety
D. The infant has not yet begun to crawl
Correct Answer: D
Explanation: While infants develop at different rates, most infants should be crawling or
creeping by 9 to 10 months of age. The inability to sit unsupported or a lack of vocalization
would be more significant, but crawling is a key gross motor milestone for this age bracket.
The nurse should perform a standardized screening tool to determine if the delay is
significant.
5. A nurse is teaching parents of a child with Cystic Fibrosis (CF) about nutritional
requirements. Which instruction is most important?
A. Administer pancreatic enzymes with every meal and snack
B. Provide a low-fat, low-calorie diet
