ATI Maternal Newborn Proctored Exam Prep Complete Practice
Question Bank 3 VERSIONS
1. A nurse is caring for a client who is 38 weeks gestation and reports a
sudden gush of clear fluid from the vagina. Which of the following
actions should the nurse take first?
A. Check the fetal heart rate.
B. Assess the fluid for meconium.
C. Obtain a sterile speculum examination.
D. Instruct the client to remain on bed rest.
Correct Answer: A. Check the fetal heart rate.
Rationale: The priority action following rupture of membranes is to assess the
fetal heart rate to detect variable or late decelerations, which could indicate
cord compression or prolapse. Fetal well-being is the immediate priority.
2. A nurse is assessing a client who is 12 hours postpartum. The client's
fundus is boggy, midline, and two fingerbreadths above the umbilicus.
Which of the following actions should the nurse take first?
A. Administer methylergonovine IM.
B. Massage the fundus.
C. Assist the client to the bathroom to void.
D. Check the client's blood pressure.
Correct Answer: C. Assist the client to the bathroom to void.
,Rationale: A boggy fundus that is elevated above the umbilicus often indicates
a full bladder displacing the uterus. The first intervention is to have the client
void, which allows the uterus to contract effectively.
3. A nurse is caring for a newborn who is 6 hours old and has a
respiratory rate of 66/min, with nasal flaring and grunting. Which of
the following actions should the nurse take?
A. Continue routine monitoring; this is a normal finding.
B. Place the newborn in a supine position.
C. Notify the provider immediately.
D. Feed the newborn to provide energy.
Correct Answer: C. Notify the provider immediately.
Rationale: Normal newborn respiratory rate is 30–60/min. Tachypnea >60
with nasal flaring and grunting indicates respiratory distress and requires
immediate provider notification.
4. A nurse is teaching a prenatal class about warning signs during
pregnancy. Which of the following client statements indicates
understanding of the teaching?
A. "I should call my provider if I have swelling in my feet."
B. "I should call my provider if I have blurred vision."
C. "I should call my provider if I have mild backache."
D. "I should call my provider if I have occasional Braxton-Hicks contractions."
*Correct Answer: B. "I should call my provider if I have blurred vision."
*
,Rationale: Blurred vision or visual disturbances are a warning sign of
preeclampsia and should be reported immediately. Mild swelling, backache,
and Braxton-Hicks are normal pregnancy findings.
5. A nurse is administering betamethasone to a client at 34 weeks
gestation. Which of the following is the purpose of this medication?
A. To stop preterm labor contractions. B.
To reduce maternal blood pressure.
C. To accelerate fetal lung maturity.
D. To prevent postpartum hemorrhage.
Correct Answer: C. To accelerate fetal lung maturity.
Rationale: Betamethasone is a corticosteroid given to clients at risk for
preterm delivery (24–34 weeks) to stimulate fetal surfactant production and
accelerate lung maturity.
6. A nurse is performing a Leopold maneuver on a client. Which of the
following describes the purpose of this assessment?
A. To determine cervical dilation.
B. To assess fetal heart rate variability.
C. To determine fetal position and presentation.
D. To assess amniotic fluid volume.
Correct Answer: C. To determine fetal position and presentation.
Rationale: Leopold maneuvers are a systematic abdominal palpation
technique used to determine fetal position, presentation, and lie. They do not
assess cervical dilation or heart rate.
, 7. A nurse is assessing a client in active labor. Which of the following
findings is a sign of uterine hyperstimulation related to oxytocin
administration?
A. Contractions every 2 minutes lasting 60 seconds.
B. Contractions every 3 minutes lasting 45 seconds.
C. Contractions every 1.5 minutes lasting 90 seconds.
D. Contractions every 4 minutes lasting 50 seconds.
Correct Answer: C. Contractions every 1.5 minutes lasting 90 seconds.
Rationale: Uterine hyperstimulation is defined as >5 contractions in 10
minutes, contractions lasting >90 seconds, or a resting tone >20 mm Hg.
Option C indicates excessive frequency and duration.
Question Bank 3 VERSIONS
1. A nurse is caring for a client who is 38 weeks gestation and reports a
sudden gush of clear fluid from the vagina. Which of the following
actions should the nurse take first?
A. Check the fetal heart rate.
B. Assess the fluid for meconium.
C. Obtain a sterile speculum examination.
D. Instruct the client to remain on bed rest.
Correct Answer: A. Check the fetal heart rate.
Rationale: The priority action following rupture of membranes is to assess the
fetal heart rate to detect variable or late decelerations, which could indicate
cord compression or prolapse. Fetal well-being is the immediate priority.
2. A nurse is assessing a client who is 12 hours postpartum. The client's
fundus is boggy, midline, and two fingerbreadths above the umbilicus.
Which of the following actions should the nurse take first?
A. Administer methylergonovine IM.
B. Massage the fundus.
C. Assist the client to the bathroom to void.
D. Check the client's blood pressure.
Correct Answer: C. Assist the client to the bathroom to void.
,Rationale: A boggy fundus that is elevated above the umbilicus often indicates
a full bladder displacing the uterus. The first intervention is to have the client
void, which allows the uterus to contract effectively.
3. A nurse is caring for a newborn who is 6 hours old and has a
respiratory rate of 66/min, with nasal flaring and grunting. Which of
the following actions should the nurse take?
A. Continue routine monitoring; this is a normal finding.
B. Place the newborn in a supine position.
C. Notify the provider immediately.
D. Feed the newborn to provide energy.
Correct Answer: C. Notify the provider immediately.
Rationale: Normal newborn respiratory rate is 30–60/min. Tachypnea >60
with nasal flaring and grunting indicates respiratory distress and requires
immediate provider notification.
4. A nurse is teaching a prenatal class about warning signs during
pregnancy. Which of the following client statements indicates
understanding of the teaching?
A. "I should call my provider if I have swelling in my feet."
B. "I should call my provider if I have blurred vision."
C. "I should call my provider if I have mild backache."
D. "I should call my provider if I have occasional Braxton-Hicks contractions."
*Correct Answer: B. "I should call my provider if I have blurred vision."
*
,Rationale: Blurred vision or visual disturbances are a warning sign of
preeclampsia and should be reported immediately. Mild swelling, backache,
and Braxton-Hicks are normal pregnancy findings.
5. A nurse is administering betamethasone to a client at 34 weeks
gestation. Which of the following is the purpose of this medication?
A. To stop preterm labor contractions. B.
To reduce maternal blood pressure.
C. To accelerate fetal lung maturity.
D. To prevent postpartum hemorrhage.
Correct Answer: C. To accelerate fetal lung maturity.
Rationale: Betamethasone is a corticosteroid given to clients at risk for
preterm delivery (24–34 weeks) to stimulate fetal surfactant production and
accelerate lung maturity.
6. A nurse is performing a Leopold maneuver on a client. Which of the
following describes the purpose of this assessment?
A. To determine cervical dilation.
B. To assess fetal heart rate variability.
C. To determine fetal position and presentation.
D. To assess amniotic fluid volume.
Correct Answer: C. To determine fetal position and presentation.
Rationale: Leopold maneuvers are a systematic abdominal palpation
technique used to determine fetal position, presentation, and lie. They do not
assess cervical dilation or heart rate.
, 7. A nurse is assessing a client in active labor. Which of the following
findings is a sign of uterine hyperstimulation related to oxytocin
administration?
A. Contractions every 2 minutes lasting 60 seconds.
B. Contractions every 3 minutes lasting 45 seconds.
C. Contractions every 1.5 minutes lasting 90 seconds.
D. Contractions every 4 minutes lasting 50 seconds.
Correct Answer: C. Contractions every 1.5 minutes lasting 90 seconds.
Rationale: Uterine hyperstimulation is defined as >5 contractions in 10
minutes, contractions lasting >90 seconds, or a resting tone >20 mm Hg.
Option C indicates excessive frequency and duration.
