Fall Semester 2026–2027 ATI Detailed Answer Key
Postpartum & Newborn Updated 2026 | 190+
Questions and Answers | ATI Maternal-Newborn
Nursing Exam Prep, Practice Exam, Comprehensive
Study Guide, Test Bank, Postpartum Nursing Care,
Newborn Assessment, Neonatal Adaptation,
Breastfeeding and Lactation, Maternal Complications,
Infant Safety, Family-Centered Care, Clinical
Judgment, NCLEX-RN Review, Detailed Rationales and
Complete Revision Material
Question 1: A postpartum nurse is assessing a client who delivered vaginally 2
hours ago. The client's fundus is firm at the umbilicus and deviated to the right.
What is the nurse's priority action?
A. Document the finding as normal.
B. Reassess in 30 minutes.
C. Assist the client to void.
D. Massage the fundus firmly.
CORRECT ANSWER: C. Assist the client to void.
Rationale: A fundus that is firm but deviated to the right or left is a classic sign of a
distended bladder displacing the uterus. The priority action is to assist the client to void
to empty the bladder, which will allow the uterus to return to midline. Massaging a firm
fundus is unnecessary and can cause pain.
Question 2: A newborn is 12 hours old and has a respiratory rate of 68 breaths per
minute with mild grunting. Which of the following actions should the nurse take
first?
A. Notify the pediatrician immediately.
B. Place the newborn in a prone position.
C. Suction the newborn's mouth and nose.
D. Assess the newborn's temperature.
CORRECT ANSWER: D. Assess the newborn's temperature.
Rationale: Grunting is a sign of respiratory distress, but in a newborn, it can be caused
by cold stress. Cold stress increases oxygen consumption and can lead to hypoxia. The
first action is to assess the temperature to rule out hypothermia as a cause before
escalating to other interventions or notifying the provider.
,Question 3: A postpartum client asks the nurse why she is having heavy bleeding
with large clots 4 days after delivery. Which of the following responses is most
appropriate?
A. "This is a sign of a normal postpartum recovery."
B. "This is called late postpartum hemorrhage and we need to call the doctor."
C. "You may have a retained placental fragment, so we will monitor your vitals."
D. "This is likely due to a urinary tract infection."
CORRECT ANSWER: B. "This is called late postpartum hemorrhage and we need to
call the doctor."
Rationale: Late postpartum hemorrhage (secondary hemorrhage) occurs 24 hours to 6
weeks postpartum and is often caused by retained placental fragments or infection.
Heavy bleeding with large clots 4 days postpartum is not normal and requires
immediate medical evaluation. A is incorrect because this is not normal.
Question 4: A nurse is teaching a new mother about breastfeeding. Which of the
following statements indicates a need for further teaching?
A. "I should hear swallowing sounds during feeding."
B. "My baby should have 6-8 wet diapers a day by day 5."
C. "I will feed my baby every 4 hours to ensure adequate rest."
D. "I can use a warm compress before feeding to stimulate let-down."
CORRECT ANSWER: C. "I will feed my baby every 4 hours to ensure adequate rest."
Rationale: Breastfed newborns should be fed on demand, typically every 2-3 hours (8-
12 times in 24 hours). Feeding every 4 hours is too infrequent and may lead to poor
weight gain, jaundice, and decreased milk supply. The other statements are correct.
Question 5: A newborn is receiving phototherapy for hyperbilirubinemia. Which of
the following is a priority nursing intervention?
A. Apply lotion to the skin to prevent dryness.
B. Monitor the newborn's temperature frequently.
C. Keep the newborn dressed in warm clothing.
D. Shield the newborn's feet with blankets.
CORRECT ANSWER: B. Monitor the newborn's temperature frequently.
Rationale: Phototherapy lights can increase the newborn's temperature, leading to
hyperthermia. Frequent temperature monitoring is a priority to prevent complications.
Lotions should not be used as they can cause burns. The infant should be minimally
dressed to maximize skin exposure to light.
,Question 6: A postpartum client is Rh-negative and her newborn is Rh-positive. The
nurse anticipates administering which of the following?
A. Rho(D) immune globulin within 72 hours of birth.
B. Iron supplements to the newborn.
C. Vitamin K injection to the newborn.
D. Antibiotics to the mother.
CORRECT ANSWER: A. Rho(D) immune globulin within 72 hours of birth.
Rationale: Rh-negative mothers who deliver an Rh-positive infant require Rho(D)
immune globulin (RhoGAM) to prevent maternal sensitization and hemolytic disease of
the newborn in subsequent pregnancies. It should be administered within 72 hours of
birth.
Question 7: A nurse is assessing a newborn's reflexes. Which finding would be
considered abnormal for a 24-hour-old newborn?
A. Moro reflex present.
B. Babinski reflex present.
C. Stepping reflex absent.
D. Rooting reflex absent.
CORRECT ANSWER: D. Rooting reflex absent.
Rationale: Rooting reflex should be present at birth and is elicited by stroking the
newborn's cheek, causing them to turn toward the stimulus and open their mouth.
Absence at 24 hours could indicate neurologic impairment, prematurity, or CNS
depression. The stepping reflex may be absent in some healthy newborns.
Question 8: Which of the following findings in a postpartum client on the 3rd day
postpartum is most concerning for a potential infection?
A. Temperature of 100.2°F (37.9°C).
B. Fundus firm at 2 fingerbreadths below umbilicus.
C. Lochia rubra with a fleshy odor.
D. Breast engorgement.
CORRECT ANSWER: A. Temperature of 100.2°F (37.9°C).
Rationale: A temperature of 100.4°F (38°C) or higher on two consecutive days
(excluding the first 24 hours) is a sign of puerperal infection. A temp of 100.2°F is
nearing that threshold and warrants further assessment. The other findings are normal.
, Question 9: A newborn's parent asks the nurse about bathing. Which of the
following is the most appropriate recommendation?
A. Bathe the newborn daily with soap.
B. Sponge bathe the newborn until the cord falls off.
C. Immerse the newborn in a tub of warm water.
D. Use alcohol to clean the cord.
CORRECT ANSWER: B. Sponge bathe the newborn until the cord falls off.
Rationale: Until the umbilical cord stump falls off and the circumcision (if done) heals,
sponge baths are recommended to prevent infection. Tub baths should be avoided until
the cord is completely detached.
Question 10: A postpartum client who is GBS-positive received antibiotics during
labor. The newborn is 4 hours old. Which assessment finding requires immediate
intervention?
A. Respiratory rate of 45 breaths/min.
B. Heart rate of 155 beats/min.
C. Nasal flaring and grunting.
D. Axillary temperature of 97.8°F (36.6°C).
CORRECT ANSWER: C. Nasal flaring and grunting.
Rationale: Nasal flaring and grunting are signs of respiratory distress. A newborn of a
GBS-positive mother is at risk for early-onset sepsis (pneumonia). These findings
require immediate evaluation. The other vitals are within normal limits.
Question 11: The nurse is administering erythromycin ophthalmic ointment to a
newborn. Which of the following is the correct rationale for this intervention?
A. To prevent neonatal conjunctivitis caused by gonorrhea and chlamydia.
B. To treat a congenital eye infection.
C. To provide lubrication for the newborn's eyes.
D. To prevent retinal detachment.
CORRECT ANSWER: A. To prevent neonatal conjunctivitis caused by gonorrhea and
chlamydia.
Rationale: Erythromycin ophthalmic ointment (or tetracycline) is administered
prophylactically within 1 hour of birth to prevent ophthalmia neonatorum, which is
caused by Neisseria gonorrhoeae and Chlamydia trachomatis.
Postpartum & Newborn Updated 2026 | 190+
Questions and Answers | ATI Maternal-Newborn
Nursing Exam Prep, Practice Exam, Comprehensive
Study Guide, Test Bank, Postpartum Nursing Care,
Newborn Assessment, Neonatal Adaptation,
Breastfeeding and Lactation, Maternal Complications,
Infant Safety, Family-Centered Care, Clinical
Judgment, NCLEX-RN Review, Detailed Rationales and
Complete Revision Material
Question 1: A postpartum nurse is assessing a client who delivered vaginally 2
hours ago. The client's fundus is firm at the umbilicus and deviated to the right.
What is the nurse's priority action?
A. Document the finding as normal.
B. Reassess in 30 minutes.
C. Assist the client to void.
D. Massage the fundus firmly.
CORRECT ANSWER: C. Assist the client to void.
Rationale: A fundus that is firm but deviated to the right or left is a classic sign of a
distended bladder displacing the uterus. The priority action is to assist the client to void
to empty the bladder, which will allow the uterus to return to midline. Massaging a firm
fundus is unnecessary and can cause pain.
Question 2: A newborn is 12 hours old and has a respiratory rate of 68 breaths per
minute with mild grunting. Which of the following actions should the nurse take
first?
A. Notify the pediatrician immediately.
B. Place the newborn in a prone position.
C. Suction the newborn's mouth and nose.
D. Assess the newborn's temperature.
CORRECT ANSWER: D. Assess the newborn's temperature.
Rationale: Grunting is a sign of respiratory distress, but in a newborn, it can be caused
by cold stress. Cold stress increases oxygen consumption and can lead to hypoxia. The
first action is to assess the temperature to rule out hypothermia as a cause before
escalating to other interventions or notifying the provider.
,Question 3: A postpartum client asks the nurse why she is having heavy bleeding
with large clots 4 days after delivery. Which of the following responses is most
appropriate?
A. "This is a sign of a normal postpartum recovery."
B. "This is called late postpartum hemorrhage and we need to call the doctor."
C. "You may have a retained placental fragment, so we will monitor your vitals."
D. "This is likely due to a urinary tract infection."
CORRECT ANSWER: B. "This is called late postpartum hemorrhage and we need to
call the doctor."
Rationale: Late postpartum hemorrhage (secondary hemorrhage) occurs 24 hours to 6
weeks postpartum and is often caused by retained placental fragments or infection.
Heavy bleeding with large clots 4 days postpartum is not normal and requires
immediate medical evaluation. A is incorrect because this is not normal.
Question 4: A nurse is teaching a new mother about breastfeeding. Which of the
following statements indicates a need for further teaching?
A. "I should hear swallowing sounds during feeding."
B. "My baby should have 6-8 wet diapers a day by day 5."
C. "I will feed my baby every 4 hours to ensure adequate rest."
D. "I can use a warm compress before feeding to stimulate let-down."
CORRECT ANSWER: C. "I will feed my baby every 4 hours to ensure adequate rest."
Rationale: Breastfed newborns should be fed on demand, typically every 2-3 hours (8-
12 times in 24 hours). Feeding every 4 hours is too infrequent and may lead to poor
weight gain, jaundice, and decreased milk supply. The other statements are correct.
Question 5: A newborn is receiving phototherapy for hyperbilirubinemia. Which of
the following is a priority nursing intervention?
A. Apply lotion to the skin to prevent dryness.
B. Monitor the newborn's temperature frequently.
C. Keep the newborn dressed in warm clothing.
D. Shield the newborn's feet with blankets.
CORRECT ANSWER: B. Monitor the newborn's temperature frequently.
Rationale: Phototherapy lights can increase the newborn's temperature, leading to
hyperthermia. Frequent temperature monitoring is a priority to prevent complications.
Lotions should not be used as they can cause burns. The infant should be minimally
dressed to maximize skin exposure to light.
,Question 6: A postpartum client is Rh-negative and her newborn is Rh-positive. The
nurse anticipates administering which of the following?
A. Rho(D) immune globulin within 72 hours of birth.
B. Iron supplements to the newborn.
C. Vitamin K injection to the newborn.
D. Antibiotics to the mother.
CORRECT ANSWER: A. Rho(D) immune globulin within 72 hours of birth.
Rationale: Rh-negative mothers who deliver an Rh-positive infant require Rho(D)
immune globulin (RhoGAM) to prevent maternal sensitization and hemolytic disease of
the newborn in subsequent pregnancies. It should be administered within 72 hours of
birth.
Question 7: A nurse is assessing a newborn's reflexes. Which finding would be
considered abnormal for a 24-hour-old newborn?
A. Moro reflex present.
B. Babinski reflex present.
C. Stepping reflex absent.
D. Rooting reflex absent.
CORRECT ANSWER: D. Rooting reflex absent.
Rationale: Rooting reflex should be present at birth and is elicited by stroking the
newborn's cheek, causing them to turn toward the stimulus and open their mouth.
Absence at 24 hours could indicate neurologic impairment, prematurity, or CNS
depression. The stepping reflex may be absent in some healthy newborns.
Question 8: Which of the following findings in a postpartum client on the 3rd day
postpartum is most concerning for a potential infection?
A. Temperature of 100.2°F (37.9°C).
B. Fundus firm at 2 fingerbreadths below umbilicus.
C. Lochia rubra with a fleshy odor.
D. Breast engorgement.
CORRECT ANSWER: A. Temperature of 100.2°F (37.9°C).
Rationale: A temperature of 100.4°F (38°C) or higher on two consecutive days
(excluding the first 24 hours) is a sign of puerperal infection. A temp of 100.2°F is
nearing that threshold and warrants further assessment. The other findings are normal.
, Question 9: A newborn's parent asks the nurse about bathing. Which of the
following is the most appropriate recommendation?
A. Bathe the newborn daily with soap.
B. Sponge bathe the newborn until the cord falls off.
C. Immerse the newborn in a tub of warm water.
D. Use alcohol to clean the cord.
CORRECT ANSWER: B. Sponge bathe the newborn until the cord falls off.
Rationale: Until the umbilical cord stump falls off and the circumcision (if done) heals,
sponge baths are recommended to prevent infection. Tub baths should be avoided until
the cord is completely detached.
Question 10: A postpartum client who is GBS-positive received antibiotics during
labor. The newborn is 4 hours old. Which assessment finding requires immediate
intervention?
A. Respiratory rate of 45 breaths/min.
B. Heart rate of 155 beats/min.
C. Nasal flaring and grunting.
D. Axillary temperature of 97.8°F (36.6°C).
CORRECT ANSWER: C. Nasal flaring and grunting.
Rationale: Nasal flaring and grunting are signs of respiratory distress. A newborn of a
GBS-positive mother is at risk for early-onset sepsis (pneumonia). These findings
require immediate evaluation. The other vitals are within normal limits.
Question 11: The nurse is administering erythromycin ophthalmic ointment to a
newborn. Which of the following is the correct rationale for this intervention?
A. To prevent neonatal conjunctivitis caused by gonorrhea and chlamydia.
B. To treat a congenital eye infection.
C. To provide lubrication for the newborn's eyes.
D. To prevent retinal detachment.
CORRECT ANSWER: A. To prevent neonatal conjunctivitis caused by gonorrhea and
chlamydia.
Rationale: Erythromycin ophthalmic ointment (or tetracycline) is administered
prophylactically within 1 hour of birth to prevent ophthalmia neonatorum, which is
caused by Neisseria gonorrhoeae and Chlamydia trachomatis.
