RN MATERNAL NEWBORN ATI PROCTORED EXAM 2026 – EXAM-STYLE
QUESTIONS AND ANSWERS | VERIFIED AND WELL DETAILED ANSWERS | PLUS
RATIONALES | GUARANTEED PASS | 2026/27 LATEST UPDATE | EXAM PREP |
STUDY GUIDE | PRACTICE TEST
1. A nurse is assessing a client who is 12 hours postpartum following a vaginal
delivery. The client reports a severe, localized headache and is experiencing
photophobia. Which of the following actions should the nurse take first?
A. Administer the prescribed PRN analgesic.
B. Instruct the client to darken the room and lie flat.
C. Notify the provider immediately.
D. Assess the client's blood pressure.
Correct Answer: C. Notify the provider immediately.
*Rationale: * A severe, localized headache with photophobia in the postpartum
period is a classic sign of a post-dural puncture headache (PDPH), often following
epidural anesthesia. However, these symptoms can also mimic preeclampsia. The
priority action is to notify the provider immediately to report these findings and
obtain further orders for assessment and treatment, as this could indicate a more
serious neurological complication. While pain management and environmental
modifications (A and B) are appropriate interventions, they are not the first step.
Assessing blood pressure (D) is relevant but should not delay notifying the
provider of these specific, concerning symptoms.
,2. A nurse is reviewing the medical record of a client at 38 weeks of gestation.
Which of the following findings should the nurse report to the provider?
A. White blood cell count of 14,000/mm³
B. Fibrinogen level of 450 mg/dL
C. Platelet count of 85,000/mm³
D. Erythrocyte sedimentation rate of 30 mm/hr
Correct Answer: C. Platelet count of 85,000/mm³
*Rationale: * A platelet count of 85,000/mm³ is significantly below the normal
pregnancy range of 150,000-400,000/mm³ and indicates thrombocytopenia. This
finding can be associated with serious conditions like severe preeclampsia or
HELLP syndrome and must be reported to the provider immediately. Mild
leukocytosis (A) and elevated fibrinogen and ESR (B and D) are normal
physiological responses to pregnancy and the inflammatory state.
3. A nurse is caring for a client who is receiving magnesium sulfate for severe
preeclampsia. Which of the following findings indicates magnesium toxicity?
A. Respiratory rate of 14/min
B. Urinary output of 40 mL/hr
C. Deep tendon reflexes 3+
D. Serum magnesium level of 8.5 mEq/L
Correct Answer: D. Serum magnesium level of 8.5 mEq/L
*Rationale: * A therapeutic serum magnesium level for preeclampsia is typically
between 4 and 7 mEq/L. A level of 8.5 mEq/L is above the therapeutic range and
,indicates toxicity. Early signs of toxicity include loss of deep tendon reflexes
(hyporeflexia), which would be a 0 or 1+ response, not 3+ (C). A respiratory rate
below 12/min (A) and a urinary output of less than 30 mL/hr (B) are also signs of
toxicity, but the laboratory value is the definitive indicator in this scenario.
4. A nurse is teaching a client who is 30 weeks of gestation about signs of
preterm labor. Which of the following statements by the client indicates an
understanding of the teaching?
A. "I should call my provider if I feel a sudden gush of fluid."
B. "I will avoid sexual intercourse for the rest of my pregnancy."
C. "A dull backache that comes and goes is a normal part of pregnancy."
D. "Menstrual-like cramps are expected at this stage."
Correct Answer: A. "I should call my provider if I feel a sudden gush of fluid."
*Rationale: * A sudden gush of fluid indicates rupture of membranes, which can
precipitate preterm labor and infection. This is a classic sign of preterm labor and
requires immediate notification of the provider. While pelvic rest may be
recommended in some high-risk situations, avoiding intercourse for the entire
remainder of the pregnancy (B) is not a standard instruction for all clients. A dull,
persistent backache (C) and menstrual-like cramps (D) can be subtle signs of
preterm labor and should be reported, not dismissed as normal.
5. A nurse is assessing a newborn who is 1 hour old. Which of the following
findings is an indication of hypoglycemia?
, A. Jitteriness
B. Acrocyanosis
C. Respiratory rate of 40/min
D. Heart rate of 160/min
Correct Answer: A. Jitteriness
*Rationale: * Jitteriness is a clinical manifestation of neonatal hypoglycemia. The
newborn's brain relies heavily on glucose, and low blood sugar leads to
neurological irritability, tremors, and jitteriness. Acrocyanosis (B), a respiratory
rate of 40/min (C), and a heart rate of 160/min (D) are all normal findings in a
newborn during the first few hours of life.
6. A nurse is preparing to administer vitamin K (phytonadione) to a newborn.
The nurse should plan to administer the medication via which of the following
routes?
A. Oral
B. Subcutaneous
C. Intramuscular
D. Intravenous
Correct Answer: C. Intramuscular
*Rationale: * Vitamin K is administered intramuscularly (IM) to the newborn in the
vastus lateralis muscle to prevent hemorrhagic disease of the newborn. The IM
route provides the most reliable and rapid absorption of this fat-soluble vitamin.
QUESTIONS AND ANSWERS | VERIFIED AND WELL DETAILED ANSWERS | PLUS
RATIONALES | GUARANTEED PASS | 2026/27 LATEST UPDATE | EXAM PREP |
STUDY GUIDE | PRACTICE TEST
1. A nurse is assessing a client who is 12 hours postpartum following a vaginal
delivery. The client reports a severe, localized headache and is experiencing
photophobia. Which of the following actions should the nurse take first?
A. Administer the prescribed PRN analgesic.
B. Instruct the client to darken the room and lie flat.
C. Notify the provider immediately.
D. Assess the client's blood pressure.
Correct Answer: C. Notify the provider immediately.
*Rationale: * A severe, localized headache with photophobia in the postpartum
period is a classic sign of a post-dural puncture headache (PDPH), often following
epidural anesthesia. However, these symptoms can also mimic preeclampsia. The
priority action is to notify the provider immediately to report these findings and
obtain further orders for assessment and treatment, as this could indicate a more
serious neurological complication. While pain management and environmental
modifications (A and B) are appropriate interventions, they are not the first step.
Assessing blood pressure (D) is relevant but should not delay notifying the
provider of these specific, concerning symptoms.
,2. A nurse is reviewing the medical record of a client at 38 weeks of gestation.
Which of the following findings should the nurse report to the provider?
A. White blood cell count of 14,000/mm³
B. Fibrinogen level of 450 mg/dL
C. Platelet count of 85,000/mm³
D. Erythrocyte sedimentation rate of 30 mm/hr
Correct Answer: C. Platelet count of 85,000/mm³
*Rationale: * A platelet count of 85,000/mm³ is significantly below the normal
pregnancy range of 150,000-400,000/mm³ and indicates thrombocytopenia. This
finding can be associated with serious conditions like severe preeclampsia or
HELLP syndrome and must be reported to the provider immediately. Mild
leukocytosis (A) and elevated fibrinogen and ESR (B and D) are normal
physiological responses to pregnancy and the inflammatory state.
3. A nurse is caring for a client who is receiving magnesium sulfate for severe
preeclampsia. Which of the following findings indicates magnesium toxicity?
A. Respiratory rate of 14/min
B. Urinary output of 40 mL/hr
C. Deep tendon reflexes 3+
D. Serum magnesium level of 8.5 mEq/L
Correct Answer: D. Serum magnesium level of 8.5 mEq/L
*Rationale: * A therapeutic serum magnesium level for preeclampsia is typically
between 4 and 7 mEq/L. A level of 8.5 mEq/L is above the therapeutic range and
,indicates toxicity. Early signs of toxicity include loss of deep tendon reflexes
(hyporeflexia), which would be a 0 or 1+ response, not 3+ (C). A respiratory rate
below 12/min (A) and a urinary output of less than 30 mL/hr (B) are also signs of
toxicity, but the laboratory value is the definitive indicator in this scenario.
4. A nurse is teaching a client who is 30 weeks of gestation about signs of
preterm labor. Which of the following statements by the client indicates an
understanding of the teaching?
A. "I should call my provider if I feel a sudden gush of fluid."
B. "I will avoid sexual intercourse for the rest of my pregnancy."
C. "A dull backache that comes and goes is a normal part of pregnancy."
D. "Menstrual-like cramps are expected at this stage."
Correct Answer: A. "I should call my provider if I feel a sudden gush of fluid."
*Rationale: * A sudden gush of fluid indicates rupture of membranes, which can
precipitate preterm labor and infection. This is a classic sign of preterm labor and
requires immediate notification of the provider. While pelvic rest may be
recommended in some high-risk situations, avoiding intercourse for the entire
remainder of the pregnancy (B) is not a standard instruction for all clients. A dull,
persistent backache (C) and menstrual-like cramps (D) can be subtle signs of
preterm labor and should be reported, not dismissed as normal.
5. A nurse is assessing a newborn who is 1 hour old. Which of the following
findings is an indication of hypoglycemia?
, A. Jitteriness
B. Acrocyanosis
C. Respiratory rate of 40/min
D. Heart rate of 160/min
Correct Answer: A. Jitteriness
*Rationale: * Jitteriness is a clinical manifestation of neonatal hypoglycemia. The
newborn's brain relies heavily on glucose, and low blood sugar leads to
neurological irritability, tremors, and jitteriness. Acrocyanosis (B), a respiratory
rate of 40/min (C), and a heart rate of 160/min (D) are all normal findings in a
newborn during the first few hours of life.
6. A nurse is preparing to administer vitamin K (phytonadione) to a newborn.
The nurse should plan to administer the medication via which of the following
routes?
A. Oral
B. Subcutaneous
C. Intramuscular
D. Intravenous
Correct Answer: C. Intramuscular
*Rationale: * Vitamin K is administered intramuscularly (IM) to the newborn in the
vastus lateralis muscle to prevent hemorrhagic disease of the newborn. The IM
route provides the most reliable and rapid absorption of this fat-soluble vitamin.
