ATI RN Maternal Newborn Concept-Based
Assessment Exam Prep 2026/2027 – Verified
Q&As with Detailed Rationales (Test Bank
Bundle - 91 Questions)
---
**QUESTION 1:**
A nurse is assessing a client at 37 weeks gestation with severe preeclampsia. Which finding requires
immediate intervention?
A) 2+ proteinuria
B) Blood pressure 150/100 mmHg
C) Deep tendon reflexes 4+ with clonus
D) Facial edema
> 🎯 **CORRECT ANSWER:** C) Deep tendon reflexes 4+ with clonus
> 💡 **DETAILED RATIONALE:** Hyperreflexia with clonus indicates severe central nervous system
irritability and is a warning sign of impending eclampsia, requiring immediate seizure precautions and
magnesium sulfate administration. Proteinuria, elevated blood pressure, and edema are diagnostic
criteria for preeclampsia but are managed with antihypertensives and monitoring, not the same
emergent priority as neurological hyperexcitability signaling imminent seizure activity.
---
**QUESTION 2:**
A client receiving magnesium sulfate for preterm labor has a respiratory rate of 10/min and absent
patellar reflexes. What is the priority nursing action?
A) Administer calcium gluconate as ordered
B) Increase the magnesium sulfate infusion
C) Document findings as therapeutic effect
D) Prepare for immediate delivery
> 🎯 **CORRECT ANSWER:** A) Administer calcium gluconate as ordered
,> 💡 **DETAILED RATIONALE:** Absent deep tendon reflexes and respiratory depression are cardinal
signs of magnesium sulfate toxicity requiring immediate discontinuation of the infusion and
administration of calcium gluconate, the specific antidote that antagonizes magnesium's effects.
Increasing the infusion would worsen toxicity, therapeutic effect preserves normal DTRs, and while
delivery may be necessary for the underlying condition, reversing toxicity is the immediate priority.
---
**QUESTION 3:**
A laboring client at 6 cm dilation has late decelerations on the fetal monitor. What is the nurse's initial
action?
A) Administer oxygen and turn client to left lateral position
B) Prepare for immediate cesarean section
C) Increase oxytocin infusion rate
D) Document the finding as benign
> 🎯 **CORRECT ANSWER:** A) Administer oxygen and turn client to left lateral position
> 💡 **DETAILED RATIONALE:** Late decelerations indicate uteroplacental insufficiency causing fetal
hypoxia; repositioning to the left lateral side displaces the uterus from the vena cava improving
maternal cardiac output and placental perfusion, while oxygen maximizes available oxygen content.
Increasing oxytocin would worsen uterine hyperstimulation, late decelerations are never benign, and
cesarean is a secondary intervention if intrauterine resuscitation fails.
---
**QUESTION 4:**
A postpartum client who delivered 2 hours ago has a boggy uterus and heavy lochia rubra. What is the
priority intervention?
A) Perform fundal massage
B) Administer tocolytic medications
C) Insert indwelling urinary catheter
D) Position client flat
> 🎯 **CORRECT ANSWER:** A) Perform fundal massage
> 💡 **DETAILED RATIONALE:** A boggy (soft, non-contracted) uterus indicates uterine atony, the
leading cause of postpartum hemorrhage; fundal massage stimulates uterine contraction which
compresses open vessels at the placental site to control bleeding. Tocolytic agents relax the uterus and
,worsen bleeding, an indwelling catheter addresses bladder distention which may contribute to atony
but massage is first, and flat positioning does not address the underlying loss of uterine tone.
---
**QUESTION 5:**
A newborn's APGAR score at 1 minute is 5. What does this score indicate regarding the newborn's
transition?
A) Excellent transition with no distress
B) Moderate difficulty requiring resuscitation
C) Severe asphyxia requiring intensive care
D) The score is invalid if at 1 minute
> 🎯 **CORRECT ANSWER:** B) Moderate difficulty requiring resuscitation
> 💡 **DETAILED RATIONALE:** APGAR scores of 4-6 indicate moderate depression and the need for
stimulation, oxygen, and possibly positive pressure ventilation to support transition; scores of 7-10 are
reassuring, and scores of 0-3 represent severe depression requiring aggressive resuscitation including
chest compressions and medications. The 1-minute score guides immediate intervention while the 5-
minute score predicts neurologic outcome.
---
**QUESTION 6:**
A client at 10 weeks gestation reports nausea and vomiting throughout the day. Which dietary
recommendation is most appropriate?
A) Consume three large meals daily
B) Eat dry carbohydrates upon waking
C) Avoid all fluids for 2 hours after eating
D) Increase intake of spicy, high-fat foods
> 🎯 **CORRECT ANSWER:** B) Eat dry carbohydrates upon waking
> 💡 **DETAILED RATIONALE:** Dry crackers or toast consumed before rising increases blood glucose
gradually and absorbs gastric acids without triggering the vomiting reflex, representing first-line non-
pharmacologic management of nausea and vomiting in early pregnancy. Large meals distend the
stomach worsening nausea, spicy and fatty foods delay gastric emptying exacerbating symptoms, and
fluids should be taken between meals rather than completely avoided.
, ---
**QUESTION 7:**
A nurse is teaching a prenatal class about the signs of true labor. Which statement by a participant
indicates correct understanding?
A) "Contractions are irregular and stop with walking."
B) "Pain is felt primarily in the lower back with contractions that radiate to the abdomen."
C) "The baby drops and I can breathe easier, signaling labor within 24 hours."
D) "There is no cervical change with contractions."
> 🎯 **CORRECT ANSWER:** B) "Pain is felt primarily in the lower back with contractions that radiate to
the abdomen."
> 💡 **DETAILED RATIONALE:** True labor contractions typically start in the lower back and radiate
circumferentially to the abdomen, are regular, increase in frequency/duration/intensity, and produce
progressive cervical dilation and effacement. False labor (Braxton-Hicks) contractions are irregular and
relieved by walking, lightening occurs weeks before labor in primigravidas, and cervical change is the
definitive sign of true labor.
---
**QUESTION 8:**
A client with gestational diabetes at 38 weeks is scheduled for induction. Which fetal surveillance test
would the nurse anticipate being ordered prior to the induction?
A) Non-stress test
B) Maternal serum alpha-fetoprotein
C) Chorionic villus sampling
D) Coombs test
> 🎯 **CORRECT ANSWER:** A) Non-stress test
> 💡 **DETAILED RATIONALE:** A non-stress test evaluates fetal well-being by monitoring fetal heart
rate reactivity to movement, providing reassurance of adequate oxygenation and neurologic status
before the stress of labor induction. MSAFP screens for neural tube defects earlier in pregnancy, CVS is a
first-trimester genetic diagnostic test, and the Coombs test assesses Rh incompatibility. Antepartum
fetal surveillance is standard for high-risk pregnancies.
Assessment Exam Prep 2026/2027 – Verified
Q&As with Detailed Rationales (Test Bank
Bundle - 91 Questions)
---
**QUESTION 1:**
A nurse is assessing a client at 37 weeks gestation with severe preeclampsia. Which finding requires
immediate intervention?
A) 2+ proteinuria
B) Blood pressure 150/100 mmHg
C) Deep tendon reflexes 4+ with clonus
D) Facial edema
> 🎯 **CORRECT ANSWER:** C) Deep tendon reflexes 4+ with clonus
> 💡 **DETAILED RATIONALE:** Hyperreflexia with clonus indicates severe central nervous system
irritability and is a warning sign of impending eclampsia, requiring immediate seizure precautions and
magnesium sulfate administration. Proteinuria, elevated blood pressure, and edema are diagnostic
criteria for preeclampsia but are managed with antihypertensives and monitoring, not the same
emergent priority as neurological hyperexcitability signaling imminent seizure activity.
---
**QUESTION 2:**
A client receiving magnesium sulfate for preterm labor has a respiratory rate of 10/min and absent
patellar reflexes. What is the priority nursing action?
A) Administer calcium gluconate as ordered
B) Increase the magnesium sulfate infusion
C) Document findings as therapeutic effect
D) Prepare for immediate delivery
> 🎯 **CORRECT ANSWER:** A) Administer calcium gluconate as ordered
,> 💡 **DETAILED RATIONALE:** Absent deep tendon reflexes and respiratory depression are cardinal
signs of magnesium sulfate toxicity requiring immediate discontinuation of the infusion and
administration of calcium gluconate, the specific antidote that antagonizes magnesium's effects.
Increasing the infusion would worsen toxicity, therapeutic effect preserves normal DTRs, and while
delivery may be necessary for the underlying condition, reversing toxicity is the immediate priority.
---
**QUESTION 3:**
A laboring client at 6 cm dilation has late decelerations on the fetal monitor. What is the nurse's initial
action?
A) Administer oxygen and turn client to left lateral position
B) Prepare for immediate cesarean section
C) Increase oxytocin infusion rate
D) Document the finding as benign
> 🎯 **CORRECT ANSWER:** A) Administer oxygen and turn client to left lateral position
> 💡 **DETAILED RATIONALE:** Late decelerations indicate uteroplacental insufficiency causing fetal
hypoxia; repositioning to the left lateral side displaces the uterus from the vena cava improving
maternal cardiac output and placental perfusion, while oxygen maximizes available oxygen content.
Increasing oxytocin would worsen uterine hyperstimulation, late decelerations are never benign, and
cesarean is a secondary intervention if intrauterine resuscitation fails.
---
**QUESTION 4:**
A postpartum client who delivered 2 hours ago has a boggy uterus and heavy lochia rubra. What is the
priority intervention?
A) Perform fundal massage
B) Administer tocolytic medications
C) Insert indwelling urinary catheter
D) Position client flat
> 🎯 **CORRECT ANSWER:** A) Perform fundal massage
> 💡 **DETAILED RATIONALE:** A boggy (soft, non-contracted) uterus indicates uterine atony, the
leading cause of postpartum hemorrhage; fundal massage stimulates uterine contraction which
compresses open vessels at the placental site to control bleeding. Tocolytic agents relax the uterus and
,worsen bleeding, an indwelling catheter addresses bladder distention which may contribute to atony
but massage is first, and flat positioning does not address the underlying loss of uterine tone.
---
**QUESTION 5:**
A newborn's APGAR score at 1 minute is 5. What does this score indicate regarding the newborn's
transition?
A) Excellent transition with no distress
B) Moderate difficulty requiring resuscitation
C) Severe asphyxia requiring intensive care
D) The score is invalid if at 1 minute
> 🎯 **CORRECT ANSWER:** B) Moderate difficulty requiring resuscitation
> 💡 **DETAILED RATIONALE:** APGAR scores of 4-6 indicate moderate depression and the need for
stimulation, oxygen, and possibly positive pressure ventilation to support transition; scores of 7-10 are
reassuring, and scores of 0-3 represent severe depression requiring aggressive resuscitation including
chest compressions and medications. The 1-minute score guides immediate intervention while the 5-
minute score predicts neurologic outcome.
---
**QUESTION 6:**
A client at 10 weeks gestation reports nausea and vomiting throughout the day. Which dietary
recommendation is most appropriate?
A) Consume three large meals daily
B) Eat dry carbohydrates upon waking
C) Avoid all fluids for 2 hours after eating
D) Increase intake of spicy, high-fat foods
> 🎯 **CORRECT ANSWER:** B) Eat dry carbohydrates upon waking
> 💡 **DETAILED RATIONALE:** Dry crackers or toast consumed before rising increases blood glucose
gradually and absorbs gastric acids without triggering the vomiting reflex, representing first-line non-
pharmacologic management of nausea and vomiting in early pregnancy. Large meals distend the
stomach worsening nausea, spicy and fatty foods delay gastric emptying exacerbating symptoms, and
fluids should be taken between meals rather than completely avoided.
, ---
**QUESTION 7:**
A nurse is teaching a prenatal class about the signs of true labor. Which statement by a participant
indicates correct understanding?
A) "Contractions are irregular and stop with walking."
B) "Pain is felt primarily in the lower back with contractions that radiate to the abdomen."
C) "The baby drops and I can breathe easier, signaling labor within 24 hours."
D) "There is no cervical change with contractions."
> 🎯 **CORRECT ANSWER:** B) "Pain is felt primarily in the lower back with contractions that radiate to
the abdomen."
> 💡 **DETAILED RATIONALE:** True labor contractions typically start in the lower back and radiate
circumferentially to the abdomen, are regular, increase in frequency/duration/intensity, and produce
progressive cervical dilation and effacement. False labor (Braxton-Hicks) contractions are irregular and
relieved by walking, lightening occurs weeks before labor in primigravidas, and cervical change is the
definitive sign of true labor.
---
**QUESTION 8:**
A client with gestational diabetes at 38 weeks is scheduled for induction. Which fetal surveillance test
would the nurse anticipate being ordered prior to the induction?
A) Non-stress test
B) Maternal serum alpha-fetoprotein
C) Chorionic villus sampling
D) Coombs test
> 🎯 **CORRECT ANSWER:** A) Non-stress test
> 💡 **DETAILED RATIONALE:** A non-stress test evaluates fetal well-being by monitoring fetal heart
rate reactivity to movement, providing reassurance of adequate oxygenation and neurologic status
before the stress of labor induction. MSAFP screens for neural tube defects earlier in pregnancy, CVS is a
first-trimester genetic diagnostic test, and the Coombs test assesses Rh incompatibility. Antepartum
fetal surveillance is standard for high-risk pregnancies.
