ATI RN Maternal Newborn Concept-Based
Assessment Exam Prep 2026/2027 – Verified
Q&As with Detailed Rationales (Test Bank
Bundle - 71 Questions)
---
**QUESTION 1:**
A client at 38 weeks gestation is admitted in active labor. During the assessment, the client's cervix is 7
cm dilated, 100% effaced, and the presenting part is at 0 station. Which stage of labor is the client in?
A) Latent phase of first stage
B) Active phase of first stage
C) Transition phase of first stage
D) Second stage of labor
> 🎯 **CORRECT ANSWER:** B) Active phase of first stage
> 💡 **DETAILED RATIONALE:** The first stage of labor is divided into the latent phase (0-6 cm), active
phase (6-10 cm with rapid dilation), and transition phase (8-10 cm with strong contractions). The client
is at 7 cm, which is within the active phase; second stage begins at 10 cm (complete dilation). Transition
is part of the active phase but is typically described as 8-10 cm; however, the active phase is the most
accurate general category for 7 cm.
---
**QUESTION 2:**
A nurse is assessing a newborn's Apgar score at 1 minute and 5 minutes. What is the maximum possible
Apgar score?
A) 5
B) 8
C) 10
D) 12
> 🎯 **CORRECT ANSWER:** C) 10
,> 💡 **DETAILED RATIONALE:** The Apgar score ranges from 0 to 10, with 10 being the best possible
score. It is assessed at 1 and 5 minutes after birth and is based on five categories: heart rate, respiratory
effort, muscle tone, reflex irritability, and color, each scored 0, 1, or 2 points.
---
**QUESTION 3:**
A client who is HIV positive is in active labor. Which intervention should the nurse implement during
labor to reduce the risk of vertical transmission?
A) Administer intravenous zidovudine (AZT) during labor
B) Perform an episiotomy to shorten the second stage
C) Apply internal fetal scalp electrodes for continuous monitoring
D) Administer oral antiviral medication to the newborn immediately after birth
> 🎯 **CORRECT ANSWER:** A) Administer intravenous zidovudine (AZT) during labor
> 💡 **DETAILED RATIONALE:** IV zidovudine (AZT) is administered to HIV-positive women during labor
to reduce the risk of mother-to-child transmission by decreasing the maternal viral load. Episiotomy (B)
and scalp electrodes (C) should be avoided because they increase fetal exposure to maternal blood. The
newborn's antiviral therapy is important but does not replace the intrapartum medication.
---
**QUESTION 4:**
A client who is 24 hours postpartum has a fundus that is firm and at the level of the umbilicus. The client
reports a gush of blood when she stands up. What is the most appropriate nursing action?
A) Massage the fundus vigorously until firm
B) Document the finding as normal and continue to monitor
C) Notify the healthcare provider immediately
D) Ask the client to empty her bladder
> 🎯 **CORRECT ANSWER:** B) Document the finding as normal and continue to monitor
> 💡 **DETAILED RATIONALE:** A firm fundus at the level of the umbilicus at 24 hours postpartum is
normal. A "gush of blood" on standing is common and is usually just pooled lochia in the vagina.
Vigorous massage is unnecessary if the fundus is firm; notifying the provider is not warranted; voiding is
not indicated as the fundus is firm.
,---
**QUESTION 5:**
A client with pre-eclampsia is receiving a magnesium sulfate infusion. The nurse should have which
antidote readily available?
A) Calcium gluconate
B) Naloxone
C) Protamine sulfate
D) Dextrose 50%
> 🎯 **CORRECT ANSWER:** A) Calcium gluconate
> 💡 **DETAILED RATIONALE:** Calcium gluconate is the antidote for magnesium sulfate toxicity; it
reverses respiratory depression and cardiac arrest by displacing magnesium at the neuromuscular
junction. Naloxone is for opioid overdose; protamine sulfate is for heparin; dextrose is for hypoglycemia.
---
**QUESTION 6:**
A nurse is providing discharge teaching to a client who had a cesarean birth. Which instruction is
essential for the client?
A) "You may resume heavy lifting after 2 weeks."
B) "You should avoid sexual intercourse until your 6-week postpartum visit."
C) "You can drive as soon as you feel comfortable."
D) "You should restrict fluid intake to minimize breast engorgement."
> 🎯 **CORRECT ANSWER:** B) "You should avoid sexual intercourse until your 6-week postpartum
visit."
> 💡 **DETAILED RATIONALE:** After a cesarean birth, clients are advised to avoid sexual intercourse
and placing anything in the vagina until the 6-week postpartum checkup to prevent infection and allow
the surgical wound to heal. Heavy lifting (A) should be avoided for 6 weeks; driving (C) should be
avoided until the client is off narcotics; fluid restriction (D) is not recommended and can lead to
dehydration.
---
**QUESTION 7:**
, A client is receiving oxytocin (Pitocin) for labor augmentation. The nurse notes that the client is having
contractions every 2 minutes lasting 80 seconds. What is the priority action?
A) Continue to monitor the contractions
B) Decrease the oxytocin infusion rate
C) Administer a tocolytic medication
D) Notify the healthcare provider immediately
> 🎯 **CORRECT ANSWER:** B) Decrease the oxytocin infusion rate
> 💡 **DETAILED RATIONALE:** Contractions lasting 80 seconds and occurring every 2 minutes
represent uterine hyperstimulation (too frequent, too long), which can lead to fetal distress. The
oxytocin infusion should be decreased or stopped first to reduce uterine activity; the provider should be
notified after reducing or stopping the infusion.
---
**QUESTION 8:**
The nurse is caring for a client in active labor who has a history of a previous cesarean birth. The client
wishes to attempt a vaginal birth after cesarean (VBAC). Which finding indicates that a VBAC may be
appropriate?
A) The previous incision was a classical uterine incision
B) The client has a history of uterine rupture
C) The client has a transverse lower uterine segment incision
D) The client is experiencing signs of uterine rupture
> 🎯 **CORRECT ANSWER:** C) The client has a transverse lower uterine segment incision
> 💡 **DETAILED RATIONALE:** A lower uterine segment transverse incision (low transverse) is the
most favorable for a VBAC, as it carries the lowest risk of uterine rupture. Classical incisions (A) and
previous uterine rupture (B) are contraindications to VBAC; signs of uterine rupture (D) require
immediate intervention, not a VBAC attempt.
---
**QUESTION 9:**
A client at 34 weeks gestation is diagnosed with placenta previa. Which finding is most consistent with
this diagnosis?
A) Painless, bright red vaginal bleeding
Assessment Exam Prep 2026/2027 – Verified
Q&As with Detailed Rationales (Test Bank
Bundle - 71 Questions)
---
**QUESTION 1:**
A client at 38 weeks gestation is admitted in active labor. During the assessment, the client's cervix is 7
cm dilated, 100% effaced, and the presenting part is at 0 station. Which stage of labor is the client in?
A) Latent phase of first stage
B) Active phase of first stage
C) Transition phase of first stage
D) Second stage of labor
> 🎯 **CORRECT ANSWER:** B) Active phase of first stage
> 💡 **DETAILED RATIONALE:** The first stage of labor is divided into the latent phase (0-6 cm), active
phase (6-10 cm with rapid dilation), and transition phase (8-10 cm with strong contractions). The client
is at 7 cm, which is within the active phase; second stage begins at 10 cm (complete dilation). Transition
is part of the active phase but is typically described as 8-10 cm; however, the active phase is the most
accurate general category for 7 cm.
---
**QUESTION 2:**
A nurse is assessing a newborn's Apgar score at 1 minute and 5 minutes. What is the maximum possible
Apgar score?
A) 5
B) 8
C) 10
D) 12
> 🎯 **CORRECT ANSWER:** C) 10
,> 💡 **DETAILED RATIONALE:** The Apgar score ranges from 0 to 10, with 10 being the best possible
score. It is assessed at 1 and 5 minutes after birth and is based on five categories: heart rate, respiratory
effort, muscle tone, reflex irritability, and color, each scored 0, 1, or 2 points.
---
**QUESTION 3:**
A client who is HIV positive is in active labor. Which intervention should the nurse implement during
labor to reduce the risk of vertical transmission?
A) Administer intravenous zidovudine (AZT) during labor
B) Perform an episiotomy to shorten the second stage
C) Apply internal fetal scalp electrodes for continuous monitoring
D) Administer oral antiviral medication to the newborn immediately after birth
> 🎯 **CORRECT ANSWER:** A) Administer intravenous zidovudine (AZT) during labor
> 💡 **DETAILED RATIONALE:** IV zidovudine (AZT) is administered to HIV-positive women during labor
to reduce the risk of mother-to-child transmission by decreasing the maternal viral load. Episiotomy (B)
and scalp electrodes (C) should be avoided because they increase fetal exposure to maternal blood. The
newborn's antiviral therapy is important but does not replace the intrapartum medication.
---
**QUESTION 4:**
A client who is 24 hours postpartum has a fundus that is firm and at the level of the umbilicus. The client
reports a gush of blood when she stands up. What is the most appropriate nursing action?
A) Massage the fundus vigorously until firm
B) Document the finding as normal and continue to monitor
C) Notify the healthcare provider immediately
D) Ask the client to empty her bladder
> 🎯 **CORRECT ANSWER:** B) Document the finding as normal and continue to monitor
> 💡 **DETAILED RATIONALE:** A firm fundus at the level of the umbilicus at 24 hours postpartum is
normal. A "gush of blood" on standing is common and is usually just pooled lochia in the vagina.
Vigorous massage is unnecessary if the fundus is firm; notifying the provider is not warranted; voiding is
not indicated as the fundus is firm.
,---
**QUESTION 5:**
A client with pre-eclampsia is receiving a magnesium sulfate infusion. The nurse should have which
antidote readily available?
A) Calcium gluconate
B) Naloxone
C) Protamine sulfate
D) Dextrose 50%
> 🎯 **CORRECT ANSWER:** A) Calcium gluconate
> 💡 **DETAILED RATIONALE:** Calcium gluconate is the antidote for magnesium sulfate toxicity; it
reverses respiratory depression and cardiac arrest by displacing magnesium at the neuromuscular
junction. Naloxone is for opioid overdose; protamine sulfate is for heparin; dextrose is for hypoglycemia.
---
**QUESTION 6:**
A nurse is providing discharge teaching to a client who had a cesarean birth. Which instruction is
essential for the client?
A) "You may resume heavy lifting after 2 weeks."
B) "You should avoid sexual intercourse until your 6-week postpartum visit."
C) "You can drive as soon as you feel comfortable."
D) "You should restrict fluid intake to minimize breast engorgement."
> 🎯 **CORRECT ANSWER:** B) "You should avoid sexual intercourse until your 6-week postpartum
visit."
> 💡 **DETAILED RATIONALE:** After a cesarean birth, clients are advised to avoid sexual intercourse
and placing anything in the vagina until the 6-week postpartum checkup to prevent infection and allow
the surgical wound to heal. Heavy lifting (A) should be avoided for 6 weeks; driving (C) should be
avoided until the client is off narcotics; fluid restriction (D) is not recommended and can lead to
dehydration.
---
**QUESTION 7:**
, A client is receiving oxytocin (Pitocin) for labor augmentation. The nurse notes that the client is having
contractions every 2 minutes lasting 80 seconds. What is the priority action?
A) Continue to monitor the contractions
B) Decrease the oxytocin infusion rate
C) Administer a tocolytic medication
D) Notify the healthcare provider immediately
> 🎯 **CORRECT ANSWER:** B) Decrease the oxytocin infusion rate
> 💡 **DETAILED RATIONALE:** Contractions lasting 80 seconds and occurring every 2 minutes
represent uterine hyperstimulation (too frequent, too long), which can lead to fetal distress. The
oxytocin infusion should be decreased or stopped first to reduce uterine activity; the provider should be
notified after reducing or stopping the infusion.
---
**QUESTION 8:**
The nurse is caring for a client in active labor who has a history of a previous cesarean birth. The client
wishes to attempt a vaginal birth after cesarean (VBAC). Which finding indicates that a VBAC may be
appropriate?
A) The previous incision was a classical uterine incision
B) The client has a history of uterine rupture
C) The client has a transverse lower uterine segment incision
D) The client is experiencing signs of uterine rupture
> 🎯 **CORRECT ANSWER:** C) The client has a transverse lower uterine segment incision
> 💡 **DETAILED RATIONALE:** A lower uterine segment transverse incision (low transverse) is the
most favorable for a VBAC, as it carries the lowest risk of uterine rupture. Classical incisions (A) and
previous uterine rupture (B) are contraindications to VBAC; signs of uterine rupture (D) require
immediate intervention, not a VBAC attempt.
---
**QUESTION 9:**
A client at 34 weeks gestation is diagnosed with placenta previa. Which finding is most consistent with
this diagnosis?
A) Painless, bright red vaginal bleeding
