Maternal-Newborn ATI proctored Exam
Questions And Answers
/. A nurse is caring for a client who is in labor and experiences abruptio placenta.
Which of the following findings should the nurse expect?
A. Hypertension.
B. Uterine tenderness.
C. Fetal tachycardia.
D. Leukorrhea. - Answer-✅Uterine tenderness
Uterine tenderness is a common symptom of abruptio placentae
/.A nurse is caring for a client who is at 28 weeks of gestation and received no
immunizations during childhood.
Which of the following vaccines should the nurse plan to administer?
A. Human papillomavirus.
B. Rubella.
C. Tetanus.
D. Varicella. - Answer-✅Tetanus
Tetanus vaccine is safe and recommended during pregnancy
/.A nurse is assessing a newborn who was born via a forceps-assisted birth.
Which of the following findings should the nurse identify as an injury caused by the
forceps?
A. Depressed anterior fontanel.
B. Uneven gluteal skinfolds.
C. Epicanthal folds.
D. Facial asymmetry. - Answer-✅Facial asymmetry
Facial asymmetry can occur due to pressure from the forceps on the facial nerves
during delivery.
/.A nurse is caring for a client who is taking an oral contraceptive.
,The nurse should instruct the client to report which of the following findings to the
provider immediately?
A. Breast tenderness.
B. Persistent headaches.
C. Vaginal itching.
D. Painful intercourse. - Answer-✅Persistent headaches
Persistent headaches can be a sign of a serious side effect such as a stroke or blood
clot and should be reported immediately.
/.A nurse is caring for a client who is postpartum and just delivered a newborn who
weighs 4.5 kg (10 lb). Which of the following manifestations should the nurse recognize
as a potential sign of hemorrhage?
A. Blood pressure 88/40 mm Hg.
B. Urinary output 40 mL/hr.
C. Moderate rubra lochia.
D. Heart rate 90/min. - Answer-✅Blood pressure 88/40 mm Hg
A blood pressure of 88/40 mm Hg is lower than the normal range (90/60 to 120/80 mm
Hg) and could indicate hemorrhage.
/.A nurse is caring for a client who is in labor. Which of the following findings should
prompt the nurse to reassess the client?
A. Intense contractions lasting 45 to 60 seconds.
B. An urge to have a bowel movement during contractions.
C. A sense of excitement and warm, flushed skin.
D. Progressive sacral discomfort during contractions. - Answer-✅An urge to have a
bowel movement during contractions.
An urge to have a bowel movement during contractions could indicate that the baby's
head is descending into the birth canal, which may require immediate attention.
/.A nurse is providing teaching to the parents of a newborn about the Plastibell
circumcision technique.
Which of the following information should the nurse include?
A. "Yellow exudate will form at the surgical site in 24 hours.".
B. "Notify the provider if the end of your baby's penis appears dark red.".
C. "The Plastibell will be removed 4 hours after the procedure.".
D. "Make sure the newborn's diaper is snug.". - Answer-✅"Yellow exudate will form at
the surgical site in 24 hours."
,The nurse should include that "yellow exudate will form at the surgical site in 24 hours"
as part of the teaching to the parents. This is because the yellow exudate is a normal
sign of healing and should not be confused with infection.
/.A nurse is caring for a client who is postpartum and has a perineal laceration. Which of
the following findings places the client at risk for delayed wound healing?
A. The client is changing the perineal pad once daily.
B. The client is using witch hazel pads on the perineum.
C. The client cleans the perineum with a squeeze bottle after urinating.
D. The client's perineal suture line is well-approximated. - Answer-✅The client is
changing the perineal pad once daily
Changing the perineal pad once daily could lead to infection, which would delay wound
healing.
/.A nurse is providing teaching to a postpartum client who has a prescription for a
rubella immunization. Which of the following client statements indicates understanding
of the teaching?
A. "I should avoid breastfeeding for 2 weeks following the immunization.".
B. "I will receive a series of three immunizations and each one will be a month apart.".
C. "I will report joint pain that develops after the immunization to my provider
immediately.".
D. "I should avoid becoming pregnant for at least 1 month following the immunization.".
- Answer-✅"I should avoid becoming pregnant for at least 1 month following the
immunization."
Women are advised to avoid pregnancy for at least 1 month following rubella
immunization due to the theoretical risk to the fetus, so this statement is correct.
/.A nurse is preparing to perform a heel stick on a newborn who has a prescription for a
total serum bilirubin. Which of the following actions should the nurse take?
A. Select a 21-gauge needle to perform the procedure.
B. Apply an alcohol pad to the site after the procedure.
C. Place a cool cloth at the site for 15 min before the procedure.
D. Puncture the lateral side of the heel for the procedure. - Answer-✅Puncture the
lateral side of the heel for the procedure.
The lateral side of the heel is the correct site for a heel stick to avoid injury to the bone.
/.A nurse is caring for a client who has a placenta previa. Which of the following findings
should the nurse expect?
A. Uterine hypertonicity.
, B. Persistent headache.
C. Firm, rigid abdomen.
D. Painless, vaginal bleeding. - Answer-✅Painless, vaginal bleeding.
Painless, vaginal bleeding is a classic symptom of placenta previa, so this statement is
correct.
/.A nurse is caring for a client who is in the second stage of labor and is experiencing a
shoulder dystocia.
The provider instructs the nurse to perform the McRoberts maneuver.
Which of the following actions should the nurse take?
A. Assist the client in pulling their knees toward their abdomen.
B. Press firmly on the client's suprapubic area.
C. Move the client onto their hands and knees.
D. Apply pressure to the client's fundus. - Answer-✅Assist the client in pulling their
knees toward their abdomen.
The McRoberts maneuver involves an obstetrician or other healthcare provider flexing
the thighs of a pregnant person toward their abdomen. This maneuver helps to rotate
the pelvis and open the sacrum to release the baby's shoulder.
/.A nurse is caring for a newborn who has jaundice and a new prescription for
phototherapy.
Which of the following actions should the nurse take?
A. Turn the newborn every 4 hr.
B. Apply hydrating lotion to the newborn's skin prior to treatment.
C. Close the newborn's eyes before applying eyepatches.
D. Provide the newborn with 15 mL glucose water after each feeding. - Answer-✅Close
the newborn's eyes before applying eyepatches.
Eye covers should be used to protect the newborn's eyes from the light during
phototherapy.
/.A nurse manager is revising a maternal unit policy to ensure proper identification of
newborns.
Which of the following should the nurse include in the policy?
A. Replace the infant's identification band after his name has been recorded.
B. Check the newborn's identification using the crib card.
C. Obtain an imprint of the infant's feet prior to taking him to the nursery.
Questions And Answers
/. A nurse is caring for a client who is in labor and experiences abruptio placenta.
Which of the following findings should the nurse expect?
A. Hypertension.
B. Uterine tenderness.
C. Fetal tachycardia.
D. Leukorrhea. - Answer-✅Uterine tenderness
Uterine tenderness is a common symptom of abruptio placentae
/.A nurse is caring for a client who is at 28 weeks of gestation and received no
immunizations during childhood.
Which of the following vaccines should the nurse plan to administer?
A. Human papillomavirus.
B. Rubella.
C. Tetanus.
D. Varicella. - Answer-✅Tetanus
Tetanus vaccine is safe and recommended during pregnancy
/.A nurse is assessing a newborn who was born via a forceps-assisted birth.
Which of the following findings should the nurse identify as an injury caused by the
forceps?
A. Depressed anterior fontanel.
B. Uneven gluteal skinfolds.
C. Epicanthal folds.
D. Facial asymmetry. - Answer-✅Facial asymmetry
Facial asymmetry can occur due to pressure from the forceps on the facial nerves
during delivery.
/.A nurse is caring for a client who is taking an oral contraceptive.
,The nurse should instruct the client to report which of the following findings to the
provider immediately?
A. Breast tenderness.
B. Persistent headaches.
C. Vaginal itching.
D. Painful intercourse. - Answer-✅Persistent headaches
Persistent headaches can be a sign of a serious side effect such as a stroke or blood
clot and should be reported immediately.
/.A nurse is caring for a client who is postpartum and just delivered a newborn who
weighs 4.5 kg (10 lb). Which of the following manifestations should the nurse recognize
as a potential sign of hemorrhage?
A. Blood pressure 88/40 mm Hg.
B. Urinary output 40 mL/hr.
C. Moderate rubra lochia.
D. Heart rate 90/min. - Answer-✅Blood pressure 88/40 mm Hg
A blood pressure of 88/40 mm Hg is lower than the normal range (90/60 to 120/80 mm
Hg) and could indicate hemorrhage.
/.A nurse is caring for a client who is in labor. Which of the following findings should
prompt the nurse to reassess the client?
A. Intense contractions lasting 45 to 60 seconds.
B. An urge to have a bowel movement during contractions.
C. A sense of excitement and warm, flushed skin.
D. Progressive sacral discomfort during contractions. - Answer-✅An urge to have a
bowel movement during contractions.
An urge to have a bowel movement during contractions could indicate that the baby's
head is descending into the birth canal, which may require immediate attention.
/.A nurse is providing teaching to the parents of a newborn about the Plastibell
circumcision technique.
Which of the following information should the nurse include?
A. "Yellow exudate will form at the surgical site in 24 hours.".
B. "Notify the provider if the end of your baby's penis appears dark red.".
C. "The Plastibell will be removed 4 hours after the procedure.".
D. "Make sure the newborn's diaper is snug.". - Answer-✅"Yellow exudate will form at
the surgical site in 24 hours."
,The nurse should include that "yellow exudate will form at the surgical site in 24 hours"
as part of the teaching to the parents. This is because the yellow exudate is a normal
sign of healing and should not be confused with infection.
/.A nurse is caring for a client who is postpartum and has a perineal laceration. Which of
the following findings places the client at risk for delayed wound healing?
A. The client is changing the perineal pad once daily.
B. The client is using witch hazel pads on the perineum.
C. The client cleans the perineum with a squeeze bottle after urinating.
D. The client's perineal suture line is well-approximated. - Answer-✅The client is
changing the perineal pad once daily
Changing the perineal pad once daily could lead to infection, which would delay wound
healing.
/.A nurse is providing teaching to a postpartum client who has a prescription for a
rubella immunization. Which of the following client statements indicates understanding
of the teaching?
A. "I should avoid breastfeeding for 2 weeks following the immunization.".
B. "I will receive a series of three immunizations and each one will be a month apart.".
C. "I will report joint pain that develops after the immunization to my provider
immediately.".
D. "I should avoid becoming pregnant for at least 1 month following the immunization.".
- Answer-✅"I should avoid becoming pregnant for at least 1 month following the
immunization."
Women are advised to avoid pregnancy for at least 1 month following rubella
immunization due to the theoretical risk to the fetus, so this statement is correct.
/.A nurse is preparing to perform a heel stick on a newborn who has a prescription for a
total serum bilirubin. Which of the following actions should the nurse take?
A. Select a 21-gauge needle to perform the procedure.
B. Apply an alcohol pad to the site after the procedure.
C. Place a cool cloth at the site for 15 min before the procedure.
D. Puncture the lateral side of the heel for the procedure. - Answer-✅Puncture the
lateral side of the heel for the procedure.
The lateral side of the heel is the correct site for a heel stick to avoid injury to the bone.
/.A nurse is caring for a client who has a placenta previa. Which of the following findings
should the nurse expect?
A. Uterine hypertonicity.
, B. Persistent headache.
C. Firm, rigid abdomen.
D. Painless, vaginal bleeding. - Answer-✅Painless, vaginal bleeding.
Painless, vaginal bleeding is a classic symptom of placenta previa, so this statement is
correct.
/.A nurse is caring for a client who is in the second stage of labor and is experiencing a
shoulder dystocia.
The provider instructs the nurse to perform the McRoberts maneuver.
Which of the following actions should the nurse take?
A. Assist the client in pulling their knees toward their abdomen.
B. Press firmly on the client's suprapubic area.
C. Move the client onto their hands and knees.
D. Apply pressure to the client's fundus. - Answer-✅Assist the client in pulling their
knees toward their abdomen.
The McRoberts maneuver involves an obstetrician or other healthcare provider flexing
the thighs of a pregnant person toward their abdomen. This maneuver helps to rotate
the pelvis and open the sacrum to release the baby's shoulder.
/.A nurse is caring for a newborn who has jaundice and a new prescription for
phototherapy.
Which of the following actions should the nurse take?
A. Turn the newborn every 4 hr.
B. Apply hydrating lotion to the newborn's skin prior to treatment.
C. Close the newborn's eyes before applying eyepatches.
D. Provide the newborn with 15 mL glucose water after each feeding. - Answer-✅Close
the newborn's eyes before applying eyepatches.
Eye covers should be used to protect the newborn's eyes from the light during
phototherapy.
/.A nurse manager is revising a maternal unit policy to ensure proper identification of
newborns.
Which of the following should the nurse include in the policy?
A. Replace the infant's identification band after his name has been recorded.
B. Check the newborn's identification using the crib card.
C. Obtain an imprint of the infant's feet prior to taking him to the nursery.
