VATI RN Maternal-Newborn Assessment Questions 2026/2027-
Complete Questions with Verified Answers & Detailed Explanations |
Graded A+
Question 1
A 24-year-old primigravida at 39 weeks' gestation arrives in the labor and
delivery unit reporting contractions every 3 minutes for the past hour. During
assessment, the fetal heart rate baseline is 145 beats/min with moderate
variability and accelerations. The cervix is 6 cm dilated, 100% effaced, and the
fetus is at 0 station. Which nursing action is the priority?
A. Encourage the client to ambulate in the hallway.
B. Continue monitoring labor progress and fetal status while providing
comfort measures.
C. Prepare the client immediately for cesarean birth.
D. Administer terbutaline to slow contractions.
Correct Answer: B. Continue monitoring labor progress and fetal status
while providing comfort measures.
Explanation:
The client is in the active phase of the first stage of labor with reassuring fetal
heart rate findings. Ongoing assessment, emotional support, and pain
management are appropriate.
Question 2
A nurse is caring for a client who is receiving oxytocin for labor augmentation.
Which finding requires the nurse to discontinue the infusion immediately?
A. Contractions every 3 minutes lasting 60 seconds.
B. Moderate fetal heart rate variability.
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,C. Late decelerations with uterine tachysystole.
D. Cervical dilation progressing from 5 cm to 6 cm.
Correct Answer: C. Late decelerations with uterine tachysystole.
Explanation:
Oxytocin should be stopped immediately when uterine tachysystole or
nonreassuring fetal heart rate patterns occur because they may indicate fetal
hypoxia.
Question 3
A client at 32 weeks' gestation reports severe headache, blurred vision, and
epigastric pain. Blood pressure is 170/112 mmHg. Which complication should
the nurse suspect?
A. Gestational diabetes.
B. Severe preeclampsia.
C. Hyperemesis gravidarum.
D. Placenta previa.
Correct Answer: B. Severe preeclampsia.
Explanation:
Severe hypertension accompanied by headache, visual disturbances, and
epigastric pain are classic manifestations of severe preeclampsia.
Question 4
A postpartum client has saturated one perineal pad in 15 minutes. The uterus
is boggy and displaced above the umbilicus. Which nursing intervention
should occur first?
A. Administer pain medication.
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,B. Massage the uterine fundus and assess bladder distention.
C. Encourage breastfeeding later.
D. Obtain a complete blood count.
Correct Answer: B. Massage the uterine fundus and assess bladder
distention.
Explanation:
Uterine atony is the leading cause of postpartum hemorrhage. Fundal massage
and bladder assessment are immediate nursing priorities.
Question 5
A nurse is caring for a newborn 2 hours after birth. Which assessment finding
requires immediate intervention?
A. Respiratory rate of 64/min with grunting and nasal flaring.
B. Acrocyanosis.
C. Heart rate of 140/min.
D. Temperature of 36.8°C (98.2°F).
Correct Answer: A. Respiratory rate of 64/min with grunting and nasal
flaring.
Explanation:
Grunting, nasal flaring, and tachypnea indicate respiratory distress requiring
prompt evaluation.
Question 6
A client at 30 weeks' gestation presents with painless bright red vaginal
bleeding. Which condition should the nurse suspect?
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, A. Placenta previa.
B. Placental abruption.
C. Ectopic pregnancy.
D. Uterine rupture.
Correct Answer: A. Placenta previa.
Explanation:
Placenta previa typically presents with painless bright red bleeding during the
second half of pregnancy.
Question 7
Which fetal heart rate pattern is considered reassuring?
A. Moderate variability with accelerations.
B. Persistent late decelerations.
C. Minimal variability with recurrent variable decelerations.
D. Prolonged fetal bradycardia.
Correct Answer: A. Moderate variability with accelerations.
Explanation:
Moderate variability and accelerations indicate adequate fetal oxygenation.
Question 8
A client receiving magnesium sulfate for preeclampsia has absent deep tendon
reflexes, respiratory rate of 10/min, and urine output of 20 mL/hr. Which
medication should the nurse prepare?
A. Oxytocin.
4|Page
Complete Questions with Verified Answers & Detailed Explanations |
Graded A+
Question 1
A 24-year-old primigravida at 39 weeks' gestation arrives in the labor and
delivery unit reporting contractions every 3 minutes for the past hour. During
assessment, the fetal heart rate baseline is 145 beats/min with moderate
variability and accelerations. The cervix is 6 cm dilated, 100% effaced, and the
fetus is at 0 station. Which nursing action is the priority?
A. Encourage the client to ambulate in the hallway.
B. Continue monitoring labor progress and fetal status while providing
comfort measures.
C. Prepare the client immediately for cesarean birth.
D. Administer terbutaline to slow contractions.
Correct Answer: B. Continue monitoring labor progress and fetal status
while providing comfort measures.
Explanation:
The client is in the active phase of the first stage of labor with reassuring fetal
heart rate findings. Ongoing assessment, emotional support, and pain
management are appropriate.
Question 2
A nurse is caring for a client who is receiving oxytocin for labor augmentation.
Which finding requires the nurse to discontinue the infusion immediately?
A. Contractions every 3 minutes lasting 60 seconds.
B. Moderate fetal heart rate variability.
1|Page
,C. Late decelerations with uterine tachysystole.
D. Cervical dilation progressing from 5 cm to 6 cm.
Correct Answer: C. Late decelerations with uterine tachysystole.
Explanation:
Oxytocin should be stopped immediately when uterine tachysystole or
nonreassuring fetal heart rate patterns occur because they may indicate fetal
hypoxia.
Question 3
A client at 32 weeks' gestation reports severe headache, blurred vision, and
epigastric pain. Blood pressure is 170/112 mmHg. Which complication should
the nurse suspect?
A. Gestational diabetes.
B. Severe preeclampsia.
C. Hyperemesis gravidarum.
D. Placenta previa.
Correct Answer: B. Severe preeclampsia.
Explanation:
Severe hypertension accompanied by headache, visual disturbances, and
epigastric pain are classic manifestations of severe preeclampsia.
Question 4
A postpartum client has saturated one perineal pad in 15 minutes. The uterus
is boggy and displaced above the umbilicus. Which nursing intervention
should occur first?
A. Administer pain medication.
2|Page
,B. Massage the uterine fundus and assess bladder distention.
C. Encourage breastfeeding later.
D. Obtain a complete blood count.
Correct Answer: B. Massage the uterine fundus and assess bladder
distention.
Explanation:
Uterine atony is the leading cause of postpartum hemorrhage. Fundal massage
and bladder assessment are immediate nursing priorities.
Question 5
A nurse is caring for a newborn 2 hours after birth. Which assessment finding
requires immediate intervention?
A. Respiratory rate of 64/min with grunting and nasal flaring.
B. Acrocyanosis.
C. Heart rate of 140/min.
D. Temperature of 36.8°C (98.2°F).
Correct Answer: A. Respiratory rate of 64/min with grunting and nasal
flaring.
Explanation:
Grunting, nasal flaring, and tachypnea indicate respiratory distress requiring
prompt evaluation.
Question 6
A client at 30 weeks' gestation presents with painless bright red vaginal
bleeding. Which condition should the nurse suspect?
3|Page
, A. Placenta previa.
B. Placental abruption.
C. Ectopic pregnancy.
D. Uterine rupture.
Correct Answer: A. Placenta previa.
Explanation:
Placenta previa typically presents with painless bright red bleeding during the
second half of pregnancy.
Question 7
Which fetal heart rate pattern is considered reassuring?
A. Moderate variability with accelerations.
B. Persistent late decelerations.
C. Minimal variability with recurrent variable decelerations.
D. Prolonged fetal bradycardia.
Correct Answer: A. Moderate variability with accelerations.
Explanation:
Moderate variability and accelerations indicate adequate fetal oxygenation.
Question 8
A client receiving magnesium sulfate for preeclampsia has absent deep tendon
reflexes, respiratory rate of 10/min, and urine output of 20 mL/hr. Which
medication should the nurse prepare?
A. Oxytocin.
4|Page
