NRSG 112 Exam 2 V1 | NRSG 112 Maternal-Child
Nursing | Actual Q&A with Rationale (NRSG112
Exam 2) | Ivy Tech
1. A nurse is monitoring a client in labor and notes a pattern of variable decelerations on the
fetal heart rate monitor. Which of the following should be the nurse’s priority action?
A. Increase the rate of the intravenous maintenance fluids
B. Change the client’s position to a lateral or knee-chest position
C. Prepare the client for an immediate cesarean delivery
D. Administer oxygen at 10 L/min via a nonrebreather mask
E. Document the finding as a normal physiological response to labor
F. Perform a vaginal examination to check for umbilical cord prolapse
Correct Answer: B
Explanation: Variable decelerations are typically caused by umbilical cord compression,
and the first nursing action should be to relieve that pressure by repositioning the client.
Lateral or knee-chest positions are most effective in shifting the fetus and freeing the cord.
The nurse should also continue to monitor the fetal heart rate response following the
intervention and prepare for further medical orders if the pattern persists.
,2. A nurse is caring for a client who is at 38 weeks of gestation and is in the active phase of
the first stage of labor. Which of the following findings should the nurse expect?
A. Dilation of the cervix from 4 to 7 cm
B. Dilation of the cervix from 8 to 10 cm
C. Contractions occurring every 10 to 15 minutes
D. The client reports a feeling of intense rectal pressure
Correct Answer: A
Explanation: The active phase of the first stage of labor is characterized by cervical
dilation from 4 cm to 7 cm. During this phase, contractions become more regular, stronger,
and more frequent, typically occurring every 3 to 5 minutes. This phase is distinct from the
latent phase (0-3 cm) and the transition phase (8-10 cm).
3. A nurse is caring for a client who is receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following findings is the priority for the nurse to report to the
provider?
A. Urinary output of 40 mL/hr
B. Respirations 10/min
C. Generalized edema in the lower extremities
D. Absence of a headache
Correct Answer: B
,Explanation: Magnesium sulfate toxicity is a serious complication that can lead to
respiratory depression and cardiac arrest. A respiratory rate below 12/min is a critical sign
of toxicity and requires immediate intervention, including stopping the infusion and
notifying the provider. The nurse must also monitor for decreased deep tendon reflexes
and significantly low urinary output as additional signs of toxicity.
4. Which of the following interventions should a nurse include in the plan of care for a client
who is 2 hours postpartum and has a boggy uterus?
A. Encourage the client to remain on bed rest
B. Perform fundal massage until the uterus is firm
C. Administer a sedative to promote rest
D. Apply a warm compress to the lower abdomen
E. Insert a Foley catheter immediately
Correct Answer: B
Explanation: A boggy uterus indicates uterine atony, which is the leading cause of
postpartum hemorrhage. The initial and most critical intervention is to perform fundal
massage to stimulate the uterine muscle to contract and become firm. If the uterus remains
boggy after massage, the nurse should then assess for a displaced bladder and check the
amount of lochia.
, 5. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Generalized petechiae
B. Acrocyanosis of the hands and feet
C. Respiratory rate of 50 breaths/min
D. Small amount of vernix caseosa in the skin folds
Correct Answer: A
Explanation: Generalized petechiae in a newborn can indicate a systemic infection or a
clotting disorder and must be reported immediately for further investigation. Acrocyanosis
is a normal finding in the first 24 to 48 hours as the peripheral circulation stabilizes. A
respiratory rate of 50/min is within the normal range of 30 to 60/min for a newborn.
6. A nurse is providing discharge teaching to a new mother about newborn safety. Which of
the following instructions should the nurse include?
A. Place the newborn on their stomach for sleeping
B. Ensure the car seat is forward-facing in the back seat
C. Maintain the water heater temperature at or below 120°F (49°C)
D. Use a soft pillow in the crib to support the newborn’s head
Correct Answer: C
Nursing | Actual Q&A with Rationale (NRSG112
Exam 2) | Ivy Tech
1. A nurse is monitoring a client in labor and notes a pattern of variable decelerations on the
fetal heart rate monitor. Which of the following should be the nurse’s priority action?
A. Increase the rate of the intravenous maintenance fluids
B. Change the client’s position to a lateral or knee-chest position
C. Prepare the client for an immediate cesarean delivery
D. Administer oxygen at 10 L/min via a nonrebreather mask
E. Document the finding as a normal physiological response to labor
F. Perform a vaginal examination to check for umbilical cord prolapse
Correct Answer: B
Explanation: Variable decelerations are typically caused by umbilical cord compression,
and the first nursing action should be to relieve that pressure by repositioning the client.
Lateral or knee-chest positions are most effective in shifting the fetus and freeing the cord.
The nurse should also continue to monitor the fetal heart rate response following the
intervention and prepare for further medical orders if the pattern persists.
,2. A nurse is caring for a client who is at 38 weeks of gestation and is in the active phase of
the first stage of labor. Which of the following findings should the nurse expect?
A. Dilation of the cervix from 4 to 7 cm
B. Dilation of the cervix from 8 to 10 cm
C. Contractions occurring every 10 to 15 minutes
D. The client reports a feeling of intense rectal pressure
Correct Answer: A
Explanation: The active phase of the first stage of labor is characterized by cervical
dilation from 4 cm to 7 cm. During this phase, contractions become more regular, stronger,
and more frequent, typically occurring every 3 to 5 minutes. This phase is distinct from the
latent phase (0-3 cm) and the transition phase (8-10 cm).
3. A nurse is caring for a client who is receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following findings is the priority for the nurse to report to the
provider?
A. Urinary output of 40 mL/hr
B. Respirations 10/min
C. Generalized edema in the lower extremities
D. Absence of a headache
Correct Answer: B
,Explanation: Magnesium sulfate toxicity is a serious complication that can lead to
respiratory depression and cardiac arrest. A respiratory rate below 12/min is a critical sign
of toxicity and requires immediate intervention, including stopping the infusion and
notifying the provider. The nurse must also monitor for decreased deep tendon reflexes
and significantly low urinary output as additional signs of toxicity.
4. Which of the following interventions should a nurse include in the plan of care for a client
who is 2 hours postpartum and has a boggy uterus?
A. Encourage the client to remain on bed rest
B. Perform fundal massage until the uterus is firm
C. Administer a sedative to promote rest
D. Apply a warm compress to the lower abdomen
E. Insert a Foley catheter immediately
Correct Answer: B
Explanation: A boggy uterus indicates uterine atony, which is the leading cause of
postpartum hemorrhage. The initial and most critical intervention is to perform fundal
massage to stimulate the uterine muscle to contract and become firm. If the uterus remains
boggy after massage, the nurse should then assess for a displaced bladder and check the
amount of lochia.
, 5. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Generalized petechiae
B. Acrocyanosis of the hands and feet
C. Respiratory rate of 50 breaths/min
D. Small amount of vernix caseosa in the skin folds
Correct Answer: A
Explanation: Generalized petechiae in a newborn can indicate a systemic infection or a
clotting disorder and must be reported immediately for further investigation. Acrocyanosis
is a normal finding in the first 24 to 48 hours as the peripheral circulation stabilizes. A
respiratory rate of 50/min is within the normal range of 30 to 60/min for a newborn.
6. A nurse is providing discharge teaching to a new mother about newborn safety. Which of
the following instructions should the nurse include?
A. Place the newborn on their stomach for sleeping
B. Ensure the car seat is forward-facing in the back seat
C. Maintain the water heater temperature at or below 120°F (49°C)
D. Use a soft pillow in the crib to support the newborn’s head
Correct Answer: C
