NRSG 112 Exam 2 V2 | NRSG 112 Maternal-Child
Nursing | Actual Q&A with Rationale (NRSG112
Exam 2) | Ivy Tech
1. A nurse is assessing a newborn 5 minutes after birth. The infant has a heart rate of 105, a
vigorous cry, active movement of all extremities, a sneeze when suctioned, and bluish
extremities with a pink trunk. What is the Apgar score?
A. 8
B. 10
C. 9
D. 7
E. 6
Correct Answer: C
Explanation: The infant receives 2 points for heart rate over 100, 2 points for respiratory
effort (vigorous cry), 2 points for muscle tone (active movement), 2 points for reflex
irritability (sneeze), and 1 point for color (acrocyanosis). This results in a total score of 9.
Apgar scores are calculated at 1 and 5 minutes to assess the newborn’s transition to
extrauterine life.
,2. A nurse is caring for a client who is in the first stage of labor. The nurse observes a late
deceleration on the fetal heart rate monitor. Which of the following actions should the nurse
take first?
A. Increase the IV fluid rate
B. Turn the client to a side-lying position
C. Administer oxygen via nonrebreather mask
D. Notify the primary care provider
Correct Answer: B
Explanation: Late decelerations indicate uteroplacental insufficiency, often caused by
maternal hypotension or compression of the vena cava. The first action the nurse should
take is to reposition the client to a side-lying position to improve blood flow to the
placenta. Subsequent actions include increasing IV fluids, administering oxygen, and
notifying the provider if the pattern persists.
3. A client at 32 weeks gestation is admitted with a diagnosis of preeclampsia. Which of the
following findings is most concerning and requires immediate intervention?
A. 1+ pedal edema
B. 300 mg of protein in a 24-hour urine collection
C. Epigastric pain
D. Blood pressure of 145/95 mmHg
,Correct Answer: C
Explanation: Epigastric pain in a client with preeclampsia is a classic sign of liver
involvement or hepatic ischemia, which can precede a seizure (eclampsia) or indicate
HELLP syndrome. While blood pressure and proteinuria are criteria for diagnosis, severe
RUQ or epigastric pain signifies clinical worsening. The nurse should immediately report
this finding and prepare for potential seizure precautions or delivery.
4. Which of the following interventions should the nurse perform for a client who is receiving
magnesium sulfate for preeclampsia?
A. Check blood pressure every 4 hours
B. Limit oral fluid intake to 2000 mL per day
C. Monitor deep tendon reflexes every hour
D. Keep the room well-lit to prevent falls
Correct Answer: C
Explanation: Magnesium sulfate is a central nervous system depressant used to prevent
seizures, and monitoring deep tendon reflexes (DTRs) is crucial to detect magnesium
toxicity. Loss of DTRs is one of the earliest signs of toxicity, followed by respiratory
depression and cardiac arrest. The nurse should also maintain a quiet, darkened
environment to reduce CNS stimulation and have calcium gluconate available as an
antidote.
, 5. A nurse is teaching a new mother about breastfeeding. Which statement by the mother
indicates a need for further teaching?
A. I should offer the breast every 2 to 3 hours
B. I will wait for the baby to open their mouth wide before latching
C. I should hear my baby swallowing during the feeding
D. I will wash my nipples with soap and water after each feeding
Correct Answer: D
Explanation: Washing nipples with soap can remove natural oils and lead to drying and
cracking, which increases the risk of infection and pain. The mother should be taught to
clean the nipples with plain water and allow them to air dry or apply a bit of expressed
colostrum. Understanding proper latch and feeding frequency are essential components of
successful breastfeeding education.
6. A client is in the active phase of the first stage of labor. The nurse notes that the cervix is
dilated to 5 cm and contractions are occurring every 3 minutes. Which of the following is the
priority assessment?
A. Maternal blood pressure
B. Fetal heart rate pattern
C. Maternal pain level
D. Status of the membranes
Nursing | Actual Q&A with Rationale (NRSG112
Exam 2) | Ivy Tech
1. A nurse is assessing a newborn 5 minutes after birth. The infant has a heart rate of 105, a
vigorous cry, active movement of all extremities, a sneeze when suctioned, and bluish
extremities with a pink trunk. What is the Apgar score?
A. 8
B. 10
C. 9
D. 7
E. 6
Correct Answer: C
Explanation: The infant receives 2 points for heart rate over 100, 2 points for respiratory
effort (vigorous cry), 2 points for muscle tone (active movement), 2 points for reflex
irritability (sneeze), and 1 point for color (acrocyanosis). This results in a total score of 9.
Apgar scores are calculated at 1 and 5 minutes to assess the newborn’s transition to
extrauterine life.
,2. A nurse is caring for a client who is in the first stage of labor. The nurse observes a late
deceleration on the fetal heart rate monitor. Which of the following actions should the nurse
take first?
A. Increase the IV fluid rate
B. Turn the client to a side-lying position
C. Administer oxygen via nonrebreather mask
D. Notify the primary care provider
Correct Answer: B
Explanation: Late decelerations indicate uteroplacental insufficiency, often caused by
maternal hypotension or compression of the vena cava. The first action the nurse should
take is to reposition the client to a side-lying position to improve blood flow to the
placenta. Subsequent actions include increasing IV fluids, administering oxygen, and
notifying the provider if the pattern persists.
3. A client at 32 weeks gestation is admitted with a diagnosis of preeclampsia. Which of the
following findings is most concerning and requires immediate intervention?
A. 1+ pedal edema
B. 300 mg of protein in a 24-hour urine collection
C. Epigastric pain
D. Blood pressure of 145/95 mmHg
,Correct Answer: C
Explanation: Epigastric pain in a client with preeclampsia is a classic sign of liver
involvement or hepatic ischemia, which can precede a seizure (eclampsia) or indicate
HELLP syndrome. While blood pressure and proteinuria are criteria for diagnosis, severe
RUQ or epigastric pain signifies clinical worsening. The nurse should immediately report
this finding and prepare for potential seizure precautions or delivery.
4. Which of the following interventions should the nurse perform for a client who is receiving
magnesium sulfate for preeclampsia?
A. Check blood pressure every 4 hours
B. Limit oral fluid intake to 2000 mL per day
C. Monitor deep tendon reflexes every hour
D. Keep the room well-lit to prevent falls
Correct Answer: C
Explanation: Magnesium sulfate is a central nervous system depressant used to prevent
seizures, and monitoring deep tendon reflexes (DTRs) is crucial to detect magnesium
toxicity. Loss of DTRs is one of the earliest signs of toxicity, followed by respiratory
depression and cardiac arrest. The nurse should also maintain a quiet, darkened
environment to reduce CNS stimulation and have calcium gluconate available as an
antidote.
, 5. A nurse is teaching a new mother about breastfeeding. Which statement by the mother
indicates a need for further teaching?
A. I should offer the breast every 2 to 3 hours
B. I will wait for the baby to open their mouth wide before latching
C. I should hear my baby swallowing during the feeding
D. I will wash my nipples with soap and water after each feeding
Correct Answer: D
Explanation: Washing nipples with soap can remove natural oils and lead to drying and
cracking, which increases the risk of infection and pain. The mother should be taught to
clean the nipples with plain water and allow them to air dry or apply a bit of expressed
colostrum. Understanding proper latch and feeding frequency are essential components of
successful breastfeeding education.
6. A client is in the active phase of the first stage of labor. The nurse notes that the cervix is
dilated to 5 cm and contractions are occurring every 3 minutes. Which of the following is the
priority assessment?
A. Maternal blood pressure
B. Fetal heart rate pattern
C. Maternal pain level
D. Status of the membranes
