NRSG 112 Exam 1 V3 | NRSG 112 Maternal-Child
Nursing | Actual Q&A with Rationale (NRSG112
Exam 1) | Ivy Tech
1. A nurse is caring for a client who is at 38 weeks of gestation and reports sudden, painless
bright red vaginal bleeding. Which of the following conditions should the nurse suspect?
A. Placenta previa
B. Abruptio placentae
C. Vasa previa
D. Uterine rupture
Correct Answer: A
Explanation: Placenta previa is characterized by painless, bright red vaginal bleeding
during the third trimester as the cervix begins to dilate. In contrast, abruptio placentae
typically presents with intense abdominal pain and dark red bleeding. The nurse must
avoid performing a vaginal exam until placenta previa is ruled out by ultrasound.
2. A client at 12 weeks of gestation asks the nurse about the frequency of prenatal visits.
According to standard guidelines for an uncomplicated pregnancy, how often should she be
seen until 28 weeks?
A. Every 2 weeks
B. Every 4 weeks
,C. Every week
D. Every 3 weeks
Correct Answer: B
Explanation: Standard prenatal care for a low-risk pregnancy involves monthly visits
(every 4 weeks) through the 28th week of gestation. Starting at 28 weeks, the frequency
increases to every 2 weeks until 36 weeks, followed by weekly visits until delivery. This
schedule allows for consistent monitoring of maternal blood pressure, fetal heart tones,
and fundal height.
3. Which of the following findings are considered presumptive signs of pregnancy? Select all
that apply.
A. Amenorrhea
B. Nausea and vomiting
C. Goodell’s sign
D. Fetal heart tones
E. Breast sensitivity
Correct Answer: A, B, E
Explanation: Presumptive signs are subjective changes reported by the woman, such as
amenorrhea, fatigue, and breast changes. Probable signs are objective findings observed by
the examiner like Goodell’s sign or a positive pregnancy test, but they do not confirm
,pregnancy. Positive signs are definitive proof of a fetus, including ultrasound visualization
or audible fetal heart sounds.
4. A nurse is assessing a newborn and notes a blue-black pigmented area on the sacrum.
Which action should the nurse take?
A. Document the finding as a Mongolian spot
B. Apply a warm compress to the area
C. Notify the physician of potential child abuse
D. Request a stat coagulation profile
Correct Answer: A
Explanation: Mongolian spots are common, benign bluish-gray skin discolorations
typically found on the sacral area of infants with darker skin tones. They are often mistaken
for bruises but are actually melanocytes trapped in the dermis. The nurse should accurately
document these findings to prevent them from being confused with signs of physical
trauma later.
5. A client is in the first stage of labor, active phase. The nurse notes that the fetal heart rate
(FHR) shows early decelerations. What is the priority nursing action?
A. Turn the client to the left side
B. Administer oxygen by face mask
C. Continue to monitor the FHR
, D. Prepare for an emergency cesarean section
Correct Answer: C
Explanation: Early decelerations are caused by fetal head compression during
contractions and are considered a benign finding. They typically mirror the contraction,
reaching the nadir at the peak of the contraction. Because they are not indicative of fetal
distress, no specific intervention is required other than continued monitoring.
6. A postpartum client who is breastfeeding complains of nipple soreness. Which intervention
should the nurse recommend?
A. Wash the nipples with soap after each feeding
B. Use a nipple shield for every feeding
C. Limit breastfeeding to 5 minutes per side
D. Wear a tight-fitting bra at all times
E. Apply a few drops of breast milk to the nipples after feeding
F. Apply alcohol to toughen the skin
Correct Answer: E
Explanation: Applying breast milk to the nipples is a natural way to promote healing due
to its antibacterial and moisturizing properties. The nurse should also ensure that the
infant has a proper latch, as poor positioning is the most common cause of nipple trauma.
Nursing | Actual Q&A with Rationale (NRSG112
Exam 1) | Ivy Tech
1. A nurse is caring for a client who is at 38 weeks of gestation and reports sudden, painless
bright red vaginal bleeding. Which of the following conditions should the nurse suspect?
A. Placenta previa
B. Abruptio placentae
C. Vasa previa
D. Uterine rupture
Correct Answer: A
Explanation: Placenta previa is characterized by painless, bright red vaginal bleeding
during the third trimester as the cervix begins to dilate. In contrast, abruptio placentae
typically presents with intense abdominal pain and dark red bleeding. The nurse must
avoid performing a vaginal exam until placenta previa is ruled out by ultrasound.
2. A client at 12 weeks of gestation asks the nurse about the frequency of prenatal visits.
According to standard guidelines for an uncomplicated pregnancy, how often should she be
seen until 28 weeks?
A. Every 2 weeks
B. Every 4 weeks
,C. Every week
D. Every 3 weeks
Correct Answer: B
Explanation: Standard prenatal care for a low-risk pregnancy involves monthly visits
(every 4 weeks) through the 28th week of gestation. Starting at 28 weeks, the frequency
increases to every 2 weeks until 36 weeks, followed by weekly visits until delivery. This
schedule allows for consistent monitoring of maternal blood pressure, fetal heart tones,
and fundal height.
3. Which of the following findings are considered presumptive signs of pregnancy? Select all
that apply.
A. Amenorrhea
B. Nausea and vomiting
C. Goodell’s sign
D. Fetal heart tones
E. Breast sensitivity
Correct Answer: A, B, E
Explanation: Presumptive signs are subjective changes reported by the woman, such as
amenorrhea, fatigue, and breast changes. Probable signs are objective findings observed by
the examiner like Goodell’s sign or a positive pregnancy test, but they do not confirm
,pregnancy. Positive signs are definitive proof of a fetus, including ultrasound visualization
or audible fetal heart sounds.
4. A nurse is assessing a newborn and notes a blue-black pigmented area on the sacrum.
Which action should the nurse take?
A. Document the finding as a Mongolian spot
B. Apply a warm compress to the area
C. Notify the physician of potential child abuse
D. Request a stat coagulation profile
Correct Answer: A
Explanation: Mongolian spots are common, benign bluish-gray skin discolorations
typically found on the sacral area of infants with darker skin tones. They are often mistaken
for bruises but are actually melanocytes trapped in the dermis. The nurse should accurately
document these findings to prevent them from being confused with signs of physical
trauma later.
5. A client is in the first stage of labor, active phase. The nurse notes that the fetal heart rate
(FHR) shows early decelerations. What is the priority nursing action?
A. Turn the client to the left side
B. Administer oxygen by face mask
C. Continue to monitor the FHR
, D. Prepare for an emergency cesarean section
Correct Answer: C
Explanation: Early decelerations are caused by fetal head compression during
contractions and are considered a benign finding. They typically mirror the contraction,
reaching the nadir at the peak of the contraction. Because they are not indicative of fetal
distress, no specific intervention is required other than continued monitoring.
6. A postpartum client who is breastfeeding complains of nipple soreness. Which intervention
should the nurse recommend?
A. Wash the nipples with soap after each feeding
B. Use a nipple shield for every feeding
C. Limit breastfeeding to 5 minutes per side
D. Wear a tight-fitting bra at all times
E. Apply a few drops of breast milk to the nipples after feeding
F. Apply alcohol to toughen the skin
Correct Answer: E
Explanation: Applying breast milk to the nipples is a natural way to promote healing due
to its antibacterial and moisturizing properties. The nurse should also ensure that the
infant has a proper latch, as poor positioning is the most common cause of nipple trauma.
