NRSG 112 Final Exam V1 | NRSG 112 Maternal-
Child Nursing | Actual Q&A with Rationale
(NRSG112 Final Exam) | Ivy Tech
1. A nurse is assessing a client who is at 34 weeks of gestation and has a prescription for a
nonstress test (NST). Which of the following findings indicates a reactive NST?
A. Two or more fetal heart rate accelerations of at least 15 beats/min lasting 15 seconds in
a 20-minute period.
B. Fetal heart rate baseline of 140 to 150 beats per minute.
C. Absence of fetal movement during a 20-minute monitoring period.
D. Persistent late decelerations occurring with spontaneous uterine contractions.
Correct Answer: A
Explanation: A reactive nonstress test is a positive sign of fetal well-being characterized by
accelerations in response to fetal movement. For a fetus at 34 weeks, the criteria require at
least two accelerations of 15 beats per minute above baseline lasting for 15 seconds within
a 20-minute window. If these criteria are not met, the test is considered nonreactive and
further testing such as a biophysical profile may be indicated.
2. A nurse is caring for a client in the second stage of labor. The fetal heart rate monitor
shows late decelerations. Which of the following actions should the nurse take? (Select the
best sequence)
A. Increase the rate of the maintenance intravenous fluids.
,B. Administer oxygen at 8 to 10 L/min via nonrebreather face mask.
C. Perform a sterile vaginal examination to check for cord prolapse.
D. Turn the client to a side-lying position.
E. Prepare the client for an immediate cesarean delivery.
Correct Answer: D
Explanation: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intervention to improve oxygenation to the fetus. The priority nursing action is
to reposition the mother to her side to relieve pressure on the inferior vena cava and
improve placental perfusion. Following repositioning, the nurse should then increase IV
fluids and administer oxygen as part of the intrauterine resuscitation protocol.
3. A nurse is assessing a pregnant client for pregnancy-induced hypertension. Which of the
following findings should the nurse report to the provider as a potential sign of preeclampsia?
A. Increased appetite and weight gain of 0.5 lb per week.
B. Generalized edema in the lower extremities at the end of the day.
C. Blurred vision or double vision.
D. Presence of a 1+ deep tendon reflex.
Correct Answer: C
Explanation: Visual disturbances such as blurred vision, double vision, or seeing spots
(scotomata) are signs of cerebral edema and vasospasm associated with severe
,preeclampsia. These symptoms indicate a worsening condition that could lead to eclampsia
if not managed promptly. Other critical signs include severe headache, epigastric pain, and
significant proteinuria.
4. A nurse is providing teaching to a client who is at 10 weeks of gestation regarding normal
physical changes. Which of the following statements by the client indicates an understanding
of the teaching?
A. I should expect to feel the baby move by the end of next week.
B. It is normal for me to have white, thin vaginal discharge.
C. I will need to limit my fluid intake to reduce my frequency of urination.
D. My breasts should stop feeling tender after the first trimester ends.
Correct Answer: B
Explanation: Leukorrhea is a thin, white, milky discharge that is normal during pregnancy
due to increased estrogen levels and blood flow to the pelvic area. The client should not
limit fluid intake as hydration is essential for fetal development and maternal health.
Quickening, or fetal movement, is typically not felt by primigravida clients until 18 to 20
weeks of gestation.
5. A nurse is caring for a client who is receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following findings is a priority to report to the provider?
A. Urinary output of 20 mL/hr.
B. Flushing and a sensation of warmth.
, C. Respiratory rate of 14 breaths/min.
D. Deep tendon reflexes of 2+.
Correct Answer: A
Explanation: Magnesium sulfate is excreted by the kidneys, so a decrease in urinary
output (less than 30 mL/hr) can lead to toxic levels of the medication. The nurse must
monitor output closely to prevent magnesium toxicity, which can result in respiratory
depression and cardiac arrest. If toxicity is suspected, the nurse should immediately stop
the infusion and prepare the antidote, calcium gluconate.
6. According to Erikson’s stages of psychosocial development, which of the following is the
primary developmental task for a toddler (ages 1 to 3 years)?
A. Trust vs. Mistrust
B. Industry vs. Inferiority
C. Initiative vs. Guilt
D. Autonomy vs. Shame and Doubt
E. Identity vs. Role Confusion
Correct Answer: D
Explanation: The developmental task for toddlers is Autonomy vs. Shame and Doubt,
where they learn to exercise their will and do things for themselves. Success in this stage
leads to self-confidence, while failure or over-restriction leads to doubt in their own
Child Nursing | Actual Q&A with Rationale
(NRSG112 Final Exam) | Ivy Tech
1. A nurse is assessing a client who is at 34 weeks of gestation and has a prescription for a
nonstress test (NST). Which of the following findings indicates a reactive NST?
A. Two or more fetal heart rate accelerations of at least 15 beats/min lasting 15 seconds in
a 20-minute period.
B. Fetal heart rate baseline of 140 to 150 beats per minute.
C. Absence of fetal movement during a 20-minute monitoring period.
D. Persistent late decelerations occurring with spontaneous uterine contractions.
Correct Answer: A
Explanation: A reactive nonstress test is a positive sign of fetal well-being characterized by
accelerations in response to fetal movement. For a fetus at 34 weeks, the criteria require at
least two accelerations of 15 beats per minute above baseline lasting for 15 seconds within
a 20-minute window. If these criteria are not met, the test is considered nonreactive and
further testing such as a biophysical profile may be indicated.
2. A nurse is caring for a client in the second stage of labor. The fetal heart rate monitor
shows late decelerations. Which of the following actions should the nurse take? (Select the
best sequence)
A. Increase the rate of the maintenance intravenous fluids.
,B. Administer oxygen at 8 to 10 L/min via nonrebreather face mask.
C. Perform a sterile vaginal examination to check for cord prolapse.
D. Turn the client to a side-lying position.
E. Prepare the client for an immediate cesarean delivery.
Correct Answer: D
Explanation: Late decelerations are indicative of uteroplacental insufficiency and require
immediate intervention to improve oxygenation to the fetus. The priority nursing action is
to reposition the mother to her side to relieve pressure on the inferior vena cava and
improve placental perfusion. Following repositioning, the nurse should then increase IV
fluids and administer oxygen as part of the intrauterine resuscitation protocol.
3. A nurse is assessing a pregnant client for pregnancy-induced hypertension. Which of the
following findings should the nurse report to the provider as a potential sign of preeclampsia?
A. Increased appetite and weight gain of 0.5 lb per week.
B. Generalized edema in the lower extremities at the end of the day.
C. Blurred vision or double vision.
D. Presence of a 1+ deep tendon reflex.
Correct Answer: C
Explanation: Visual disturbances such as blurred vision, double vision, or seeing spots
(scotomata) are signs of cerebral edema and vasospasm associated with severe
,preeclampsia. These symptoms indicate a worsening condition that could lead to eclampsia
if not managed promptly. Other critical signs include severe headache, epigastric pain, and
significant proteinuria.
4. A nurse is providing teaching to a client who is at 10 weeks of gestation regarding normal
physical changes. Which of the following statements by the client indicates an understanding
of the teaching?
A. I should expect to feel the baby move by the end of next week.
B. It is normal for me to have white, thin vaginal discharge.
C. I will need to limit my fluid intake to reduce my frequency of urination.
D. My breasts should stop feeling tender after the first trimester ends.
Correct Answer: B
Explanation: Leukorrhea is a thin, white, milky discharge that is normal during pregnancy
due to increased estrogen levels and blood flow to the pelvic area. The client should not
limit fluid intake as hydration is essential for fetal development and maternal health.
Quickening, or fetal movement, is typically not felt by primigravida clients until 18 to 20
weeks of gestation.
5. A nurse is caring for a client who is receiving magnesium sulfate for the treatment of
preeclampsia. Which of the following findings is a priority to report to the provider?
A. Urinary output of 20 mL/hr.
B. Flushing and a sensation of warmth.
, C. Respiratory rate of 14 breaths/min.
D. Deep tendon reflexes of 2+.
Correct Answer: A
Explanation: Magnesium sulfate is excreted by the kidneys, so a decrease in urinary
output (less than 30 mL/hr) can lead to toxic levels of the medication. The nurse must
monitor output closely to prevent magnesium toxicity, which can result in respiratory
depression and cardiac arrest. If toxicity is suspected, the nurse should immediately stop
the infusion and prepare the antidote, calcium gluconate.
6. According to Erikson’s stages of psychosocial development, which of the following is the
primary developmental task for a toddler (ages 1 to 3 years)?
A. Trust vs. Mistrust
B. Industry vs. Inferiority
C. Initiative vs. Guilt
D. Autonomy vs. Shame and Doubt
E. Identity vs. Role Confusion
Correct Answer: D
Explanation: The developmental task for toddlers is Autonomy vs. Shame and Doubt,
where they learn to exercise their will and do things for themselves. Success in this stage
leads to self-confidence, while failure or over-restriction leads to doubt in their own
