ATI RN MAT NEWBORN ONLINE PRACTICE 2026
A EXAM QUESTIONS AND ANSWERS 100%
CORRECT!!
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation.
Which of the following findings should the nurse expect? - ANSWER Deep tendon
reflexes 4+
Fundal height 14 cm
Blood pressure 142/92 mm Hg
FHR 152/min
Answer: FHR 152/min
Rationale: The expected range for the FHR is 110/min to 160/min. The FHR is higher
earlier in gestation with an average of approximately 160/min at 20 weeks of gestation.
Therefore, this is an expected finding by the nurse.
Incorrect rationales:
DTR rationale: Deep tendon reflexes (DTRs) are an indication of the balance between
the cerebral cortex and spinal cord. The nurse should expect the client's DTR to be 2+.
Therefore, a DTR of 4+ indicates hyperreflexia.
Fundal rationale: From gestational weeks 18 to 32, the height of the fundus is
approximately equal to the number of weeks of gestation plus or minus 2 cm. Therefore,
the nurse should expect the fundal height for this client to be 16 to 20 cm.
BP rationale: An elevated blood pressure may be an indication of preeclampsia.
Therefore, the nurse should investigate this finding further and the client's blood
pressure should be evaluated more frequently.
A nurse is planning care for a client who is to undergo a nonstress test. Which of the
following actions should the nurse include in the plan of care? - ANSWER Maintain the
client NPO throughout the procedure
Place the client in a supine position
Instruct the client to massage the abdomen to stimulate fetal movement
,Instruct the client to press the provided button each time fetal movement is detected
Answer: Instruct the client to press the provided button each time fetal movement is
detected
Rationale: Fetal movement may not be evident on the fetal monitor and tracing.
Instructing the client to press the button when they detect fetal movement will ensure
that the fetal movement is noted.
Incorrect:
Maintain the client NPO throughout the procedure:
There is no indication for the client to be NPO. Sometimes clients are encouraged to
drink liquids to promote adequate hydration.
Place the client in a supine position: The client should be placed in a semi-Fowler's or
sitting position and tilted to the right or left to promote uterine perfusion and prevent
supine hypotension.
Instruct the client to massage the abdomen to stimulate fetal movement: Massaging the
abdomen does not stimulate fetal movement.
Gastrointestinal findings.
The newborn is displaying poor feeding and loose stools. These findings are
manifestations of NAS and should be reported to the provider.
Incorrect:
Respiratory findings is incorrect. The newborn's respiratory rate is within the expected
reference range of 30 to 60/min. There is no indication the newborn has an alteration in
respiratory status; therefore, this finding does not need to be reported to the provider.
Temperature is incorrect. The newborn's temperature is within the expected reference
range of 36.5° to 37.5° C (97.7° to 99.5° F). Therefore, this finding does not need to be
reported to the provider.
Oxygen saturation is incorrect. The newborn's oxygen saturation is within the expected
reference range of greater than 94%; therefore, this finding does not need to be
reported to the provider.
A nurse is caring for a newborn.
Medical History
1600: Apgar score 9 at 1 min and 9 at 5 min
Birth weight 4,706 g (10 lb 6 oz)
Gestational age 40 weeks
, Difficult vaginal birth with shoulder dystocia.
Nurses' Notes
1700: Newborn is active and moves all extremities except for right arm.
No spontaneous movement of the right arm noted.
Right arm remains at side during Moro reflex.
Physical Examination
1830:Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm
pronated with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-
Duchenne (Erb's palsy) paralysis.
Which of the following actions should the nurse plan to implement?
For each potential nursing action, click to specify if the intervention is indicated or
contraindicated for the newborn. - ANSWER Correct:
Educate the parents to begin range of motion exercises on the affected arm after 1
week is indicated.
Rationale: Passive ROM exercises of the arm are indicated to restore function of the
extremity. The initiation of these exercises is delayed for approximately 1 week to
prevent additional injury to the brachial plexus.
Assess for grasp reflex in the affected extremity is indicated. Rationale: With Erb-
Duchenne paralysis, only the upper arm is affected. The function of the wrists and
fingers should be unaffected; the nurse should assess for a palmar grasp reflex.
Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt is
indicated.
Rationale: Intermittent immobilization of the affected arm across the newborn's
abdomen can be achieved by pinning the sleeve to the shirt.
Incorrect:
Instruct parents to limit physical handling for 2 weeks is contraindicated.
Rationale: Parents and guardians should participate in the physical care of their
newborn to increase parental-infant attachment. Providing education and practice
opportunities for the parents will decrease their fears of injuring the newborn and
increase confidence and bonding.
A nurse is caring for a newborn who is 48 hr old.
Vital Signs
A EXAM QUESTIONS AND ANSWERS 100%
CORRECT!!
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation.
Which of the following findings should the nurse expect? - ANSWER Deep tendon
reflexes 4+
Fundal height 14 cm
Blood pressure 142/92 mm Hg
FHR 152/min
Answer: FHR 152/min
Rationale: The expected range for the FHR is 110/min to 160/min. The FHR is higher
earlier in gestation with an average of approximately 160/min at 20 weeks of gestation.
Therefore, this is an expected finding by the nurse.
Incorrect rationales:
DTR rationale: Deep tendon reflexes (DTRs) are an indication of the balance between
the cerebral cortex and spinal cord. The nurse should expect the client's DTR to be 2+.
Therefore, a DTR of 4+ indicates hyperreflexia.
Fundal rationale: From gestational weeks 18 to 32, the height of the fundus is
approximately equal to the number of weeks of gestation plus or minus 2 cm. Therefore,
the nurse should expect the fundal height for this client to be 16 to 20 cm.
BP rationale: An elevated blood pressure may be an indication of preeclampsia.
Therefore, the nurse should investigate this finding further and the client's blood
pressure should be evaluated more frequently.
A nurse is planning care for a client who is to undergo a nonstress test. Which of the
following actions should the nurse include in the plan of care? - ANSWER Maintain the
client NPO throughout the procedure
Place the client in a supine position
Instruct the client to massage the abdomen to stimulate fetal movement
,Instruct the client to press the provided button each time fetal movement is detected
Answer: Instruct the client to press the provided button each time fetal movement is
detected
Rationale: Fetal movement may not be evident on the fetal monitor and tracing.
Instructing the client to press the button when they detect fetal movement will ensure
that the fetal movement is noted.
Incorrect:
Maintain the client NPO throughout the procedure:
There is no indication for the client to be NPO. Sometimes clients are encouraged to
drink liquids to promote adequate hydration.
Place the client in a supine position: The client should be placed in a semi-Fowler's or
sitting position and tilted to the right or left to promote uterine perfusion and prevent
supine hypotension.
Instruct the client to massage the abdomen to stimulate fetal movement: Massaging the
abdomen does not stimulate fetal movement.
Gastrointestinal findings.
The newborn is displaying poor feeding and loose stools. These findings are
manifestations of NAS and should be reported to the provider.
Incorrect:
Respiratory findings is incorrect. The newborn's respiratory rate is within the expected
reference range of 30 to 60/min. There is no indication the newborn has an alteration in
respiratory status; therefore, this finding does not need to be reported to the provider.
Temperature is incorrect. The newborn's temperature is within the expected reference
range of 36.5° to 37.5° C (97.7° to 99.5° F). Therefore, this finding does not need to be
reported to the provider.
Oxygen saturation is incorrect. The newborn's oxygen saturation is within the expected
reference range of greater than 94%; therefore, this finding does not need to be
reported to the provider.
A nurse is caring for a newborn.
Medical History
1600: Apgar score 9 at 1 min and 9 at 5 min
Birth weight 4,706 g (10 lb 6 oz)
Gestational age 40 weeks
, Difficult vaginal birth with shoulder dystocia.
Nurses' Notes
1700: Newborn is active and moves all extremities except for right arm.
No spontaneous movement of the right arm noted.
Right arm remains at side during Moro reflex.
Physical Examination
1830:Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted. Elbow extended. Forearm
pronated with wrist and fingers flexed. Diagnosis: Brachial plexus injury resulting in Erb-
Duchenne (Erb's palsy) paralysis.
Which of the following actions should the nurse plan to implement?
For each potential nursing action, click to specify if the intervention is indicated or
contraindicated for the newborn. - ANSWER Correct:
Educate the parents to begin range of motion exercises on the affected arm after 1
week is indicated.
Rationale: Passive ROM exercises of the arm are indicated to restore function of the
extremity. The initiation of these exercises is delayed for approximately 1 week to
prevent additional injury to the brachial plexus.
Assess for grasp reflex in the affected extremity is indicated. Rationale: With Erb-
Duchenne paralysis, only the upper arm is affected. The function of the wrists and
fingers should be unaffected; the nurse should assess for a palmar grasp reflex.
Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt is
indicated.
Rationale: Intermittent immobilization of the affected arm across the newborn's
abdomen can be achieved by pinning the sleeve to the shirt.
Incorrect:
Instruct parents to limit physical handling for 2 weeks is contraindicated.
Rationale: Parents and guardians should participate in the physical care of their
newborn to increase parental-infant attachment. Providing education and practice
opportunities for the parents will decrease their fears of injuring the newborn and
increase confidence and bonding.
A nurse is caring for a newborn who is 48 hr old.
Vital Signs
