NRSG 112 Exam 4 V2 | NRSG 112 Maternal-Child
Nursing | Actual Q&A with Rationale (NRSG112
Exam 4) | Ivy Tech
1. A nurse is monitoring a client receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following findings should the nurse identify as the priority to
report to the provider?
A. Urinary output of 40 mL/hr
B. Client reports feeling warm and flushed
C. Presence of deep tendon reflexes 2+
D. Blood pressure of 148/94 mmHg
E. Respiratory rate of 10 breaths per minute
Correct Answer: E
Explanation: A respiratory rate below 12 breaths per minute is a primary indicator of
magnesium sulfate toxicity and requires immediate intervention. The nurse must stop the
infusion and notify the provider to prevent respiratory arrest. Calcium gluconate should be
readily available as the antidote for magnesium toxicity.
2. A 2-year-old child is admitted to the pediatric unit with a diagnosis of
Laryngotracheobronchitis (Croup). Which clinical manifestation should the nurse expect to
observe?
A. High-pitched drooling
,B. Visible throat membrane
C. Barking, brassy cough
D. Productive green sputum
Correct Answer: C
Explanation: Laryngotracheobronchitis is characterized by edema of the larynx and
trachea, resulting in a distinct bark-like cough. This condition typically follows a viral upper
respiratory infection and worsens at night. Nurses should monitor for inspiratory stridor
and signs of respiratory distress.
3. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Abruptio placentae
B. Preterm labor
C. Uterine rupture
D. Placenta previa
Correct Answer: D
Explanation: Painless bright red vaginal bleeding in the third trimester is the hallmark
sign of placenta previa. Unlike abruptio placentae, there is typically no abdominal pain or
uterine tenderness. A vaginal exam is strictly contraindicated until the location of the
placenta is confirmed by ultrasound.
, 4. A nurse is providing discharge teaching to the parents of a child newly diagnosed with
cystic fibrosis. Which of the following instructions regarding pancreatic enzyme replacement
therapy should be included?
A. Administer enzymes only with the morning and evening meals.
B. Crush the enteric-coated beads if the child has trouble swallowing.
C. Store the enzymes in the refrigerator to maintain potency.
D. Give the enzymes two hours after eating for maximum absorption.
E. Decrease the dose if the child develops steatorrhea.
F. Administer enzymes with every meal and every snack.
Correct Answer: F
Explanation: Pancreatic enzymes are necessary for the digestion of fats and proteins in
patients with cystic fibrosis and must be present in the duodenum when food arrives.
Therefore, they must be taken with every meal and snack throughout the day. The dosage
is adjusted based on the growth of the child and the consistency of their stools.
5. The nurse is caring for an infant with Tetralogy of Fallot who begins to have a
hypercyanotic (‘Tet’) spell. Which action should the nurse take first?
A. Administer 100% oxygen via face mask
B. Administer morphine sulfate intravenously
C. Place the infant in a knee-chest position
Nursing | Actual Q&A with Rationale (NRSG112
Exam 4) | Ivy Tech
1. A nurse is monitoring a client receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following findings should the nurse identify as the priority to
report to the provider?
A. Urinary output of 40 mL/hr
B. Client reports feeling warm and flushed
C. Presence of deep tendon reflexes 2+
D. Blood pressure of 148/94 mmHg
E. Respiratory rate of 10 breaths per minute
Correct Answer: E
Explanation: A respiratory rate below 12 breaths per minute is a primary indicator of
magnesium sulfate toxicity and requires immediate intervention. The nurse must stop the
infusion and notify the provider to prevent respiratory arrest. Calcium gluconate should be
readily available as the antidote for magnesium toxicity.
2. A 2-year-old child is admitted to the pediatric unit with a diagnosis of
Laryngotracheobronchitis (Croup). Which clinical manifestation should the nurse expect to
observe?
A. High-pitched drooling
,B. Visible throat membrane
C. Barking, brassy cough
D. Productive green sputum
Correct Answer: C
Explanation: Laryngotracheobronchitis is characterized by edema of the larynx and
trachea, resulting in a distinct bark-like cough. This condition typically follows a viral upper
respiratory infection and worsens at night. Nurses should monitor for inspiratory stridor
and signs of respiratory distress.
3. A client at 32 weeks gestation presents with painless, bright red vaginal bleeding. Which
condition should the nurse suspect?
A. Abruptio placentae
B. Preterm labor
C. Uterine rupture
D. Placenta previa
Correct Answer: D
Explanation: Painless bright red vaginal bleeding in the third trimester is the hallmark
sign of placenta previa. Unlike abruptio placentae, there is typically no abdominal pain or
uterine tenderness. A vaginal exam is strictly contraindicated until the location of the
placenta is confirmed by ultrasound.
, 4. A nurse is providing discharge teaching to the parents of a child newly diagnosed with
cystic fibrosis. Which of the following instructions regarding pancreatic enzyme replacement
therapy should be included?
A. Administer enzymes only with the morning and evening meals.
B. Crush the enteric-coated beads if the child has trouble swallowing.
C. Store the enzymes in the refrigerator to maintain potency.
D. Give the enzymes two hours after eating for maximum absorption.
E. Decrease the dose if the child develops steatorrhea.
F. Administer enzymes with every meal and every snack.
Correct Answer: F
Explanation: Pancreatic enzymes are necessary for the digestion of fats and proteins in
patients with cystic fibrosis and must be present in the duodenum when food arrives.
Therefore, they must be taken with every meal and snack throughout the day. The dosage
is adjusted based on the growth of the child and the consistency of their stools.
5. The nurse is caring for an infant with Tetralogy of Fallot who begins to have a
hypercyanotic (‘Tet’) spell. Which action should the nurse take first?
A. Administer 100% oxygen via face mask
B. Administer morphine sulfate intravenously
C. Place the infant in a knee-chest position
