ATI Rn Maternal Newborn Proctored Exam Testbank| All
Questions And Answers 2026/2027 | Verified Answers Plus
Rationales | Graded Q&A Comprehensive Study Guide | (
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1. A nurse is caring for a client who is at 38 weeks of gestation and in active labor. The
client reports a sudden, severe pain in her abdomen and a tearing sensation. The fetal
monitor reveals late decelerations and fetal bradycardia. Which of the following
complications should the nurse suspect?
A. Uterine rupture
B. Placenta previa
C. Placental abruption
D. Vasa previa
Uterine rupture is a catastrophic obstetric complication characterized by sudden, severe
abdominal pain, a tearing sensation, and sudden fetal distress such as late decelerations and
bradycardia. Placenta previa typically presents with painless bright red bleeding. Placental
abruption causes dark red bleeding and constant abdominal pain, but not a tearing sensation
or rapid loss of intrauterine pressure. Vasa previa presents with painless vaginal bleeding and
fetal distress upon rupture of membranes.
2. A nurse is assessing a newborn who is 2 hours old. Which of the following findings
should the nurse report to the provider immediately?
A. Acrocyanosis of the hands and feet
B. Presence of Epstein pearls on the hard palate
C. Intercostal retractions and nasal flaring
D. A heart rate of 140/min with irregular rhythm
Intercostal retractions and nasal flaring are classic clinical indicators of respiratory distress in
a newborn and require immediate intervention. Acrocyanosis is a normal finding in a stable
newborn during the first 24 hours of life. Epstein pearls are harmless inclusion cysts commonly
found on the hard palate. A heart rate of 140/min falls within the normal newborn range of
110 to 160/min, and periodic reactivity or minor variations can occur.
3. A nurse is providing discharge instructions to a postpartum client who received the
rubella vaccine before discharge. Which of the following statements by the client indicates
an understanding of the teaching?
A. "I can try to conceive again in 1 month."
B. "I will avoid getting pregnant for at least 28 days."
C. "I should expect a mild fever and rash for the next 3 weeks."
,D. "I need to take oral antibiotics concurrently to prevent infection."
The rubella vaccine is a live-attenuated virus, and clients are advised to avoid pregnancy for
at least 28 days (or 1 to 3 months depending on institutional protocols, standard being 28
days to 3 months) to prevent teratogenic risks to a fetus. A 1-month window is often cited as
4 weeks or 28 days; however, standard guidance specifies avoiding pregnancy for 28 days to 3
months. Mild local reactions or a transient rash can occur, but avoiding pregnancy for the
specified timeframe is the critical teratogenicity precaution.
4. A nurse is caring for a client at 32 weeks of gestation who is receiving magnesium sulfate
via continuous IV infusion for preeclampsia. Which of the following findings indicates
magnesium sulfate toxicity?
A. Blood pressure of 130/80 mm Hg
B. Respiratory rate of 10/min
C. Urine output of 40 mL/hr
D. Deep tendon reflexes of 2+
A respiratory rate of less than 12/min is a primary indicator of central nervous system
depression caused by magnesium sulfate toxicity, requiring immediate cessation of the
infusion and administration of calcium gluconate. A blood pressure of 130/80 is stable. A
urine output of 40 mL/hr is adequate (greater than 30 mL/hr is expected). Deep tendon
reflexes of 2+ are normal; hyperreflexia or absent reflexes (0) indicate toxicity.
5. A nurse is monitoring a client in labor who has an epidural anesthesia block in place.
Which of the following findings is the priority nursing intervention?
A. Assess for maternal hypotension
B. Monitor for bladder distension
C. Evaluate the progress of cervical dilation
D. Check for a positive Moro reflex in the newborn
Maternal hypotension is the most common and dangerous immediate complication following
the placement of an epidural block due to sympathetic blockade causing vasodilation.
Promptly identifying and treating hypotension with IV fluids and positioning prevents
uteroplacental hypoperfusion. While bladder distension, cervical dilation, and newborn
reflexes are important, restoring and maintaining maternal blood pressure is the immediate
priority.
6. A nurse is assessing a postpartum client 12 hours after birth. The nurse notes that the
client's fundus is boggy, displaced to the right, and 2 cm above the umbilicus. Which of the
following actions should the nurse take first?
A. Administer methylergonovine as prescribed
B. Assist the client to empty her bladder
,C. Massage the fundus until firm
D. Notify the primary healthcare provider
A boggy and displaced fundus is typically caused by a distended bladder, which prevents the
uterus from contracting effectively. Assisting the client to empty her bladder is the priority
nursing action, followed by fundal massage if needed. While fundal massage and uterotonics
like methylergonovine help manage uterine atony, correcting the underlying bladder
distension resolves the displacement and allows proper contraction.
7. A nurse is caring for a newborn immediately following birth. Which of the following
nursing actions is the highest priority?
A. Administering erythromycin ophthalmic ointment
B. Drying the newborn and establishing respirations
C. Obtaining the birth weight and head circumference
D. Administering the vitamin K injection
Establishing effective respirations and preventing cold stress through thorough drying are the
immediate priorities in newborn stabilization following the ABCs of resuscitation. Prophylactic
eye ointment, vitamin K, and anthropometric measurements are important routine care items
that can be delayed until the newborn is stable and thermoregulated.
8. A nurse is caring for a client at 36 weeks of gestation who is scheduled for a nonstress
test (NST). The nurse explains that the test is nonreactive. Which of the following actions
should the nurse anticipate next?
A. Immediate induction of labor
B. Scheduling a biophysical profile (BPP) or contraction stress test (CST)
C. Discharge home with daily fetal movement counts
D. Administration of betamethasone injections
A nonreactive NST does not automatically indicate fetal compromise, but it requires further
diagnostic evaluation, such as a biophysical profile or a contraction stress test, to assess fetal
well-being. Immediate delivery is reserved for severe distress or abnormal advanced testing.
Betamethasone is used for fetal lung maturity prior to 34 weeks gestation.
9. A nurse is teaching a client who is at 10 weeks of gestation about expected physiological
changes. Which of the following statements by the client indicates a need for further
teaching?
A. "I might experience increased white vaginal discharge called leukorrhea."
B. "I should expect to feel the baby move around 12 weeks of gestation."
C. "My heart rate might increase by about 10 to 15 beats per minute."
D. "I can expect my gums to bleed more easily when I brush my teeth."
, Fetal movement, or quickening, is typically felt by a primigravida around 18 to 20 weeks of
gestation, and by a multipara around 16 to 18 weeks. Feeling movement at 12 weeks is rare
and indicates a need for correction. Leukorrhea, increased heart rate, and hyperemic bleeding
gums are expected physiological adaptations during pregnancy.
10. A nurse is caring for a client who has preeclampsia without severe features and is
managing her care at home. Which of the following instructions should the nurse
emphasize?
A. Maintain strict bed rest in the prone position
B. Rest in a left lateral recumbent position
C. Restrict fluid intake to 1,000 mL per day
D. Consume a low-protein diet to decrease renal workload
Resting in a left lateral recumbent position relieves pressure on the vena cava, improves
placental perfusion, and enhances renal blood flow. Complete bed rest is no longer routinely
recommended due to risks of thrombosis. Fluid restriction is not indicated unless pulmonary
edema develops, and protein intake should remain normal to prevent nutritional deficits.
11. A nurse is assessing a client who is 4 hours postpartum and notes a continuous trickle of
bright red vaginal blood, a firm fundus, and a normal bladder. Which of the following
conditions should the nurse suspect?
A. Uterine atony
B. Retained placental fragments
C. Laceration of the cervix or vagina
D. Uterine inversion
A continuous trickle of bright red blood in the presence of a firm, contracted uterus is the
hallmark sign of a cervical or vaginal laceration. Uterine atony presents with a boggy or soft
fundus. Retained placental fragments typically present with a boggy fundus and late
postpartum hemorrhage. Uterine inversion presents with severe pelvic pain, hemorrhage, and
an absent fundus on palpation.
12. A nurse is caring for a client who is in the transition phase of the first stage of labor.
The client states, "I cannot take this anymore, I need to push." Which of the following
actions should the nurse take?
A. Encourage the client to begin bearing down with contractions
B. Instruct the client to use panting breaths to avoid pushing
C. Prepare the delivery room for immediate birth
D. Administer an analgesic opioid medication
During the transition phase of labor, cervical dilation is 8 to 10 cm, and the client often feels
an uncontrollable urge to push. If the cervix is not fully dilated, pushing can cause cervical
Questions And Answers 2026/2027 | Verified Answers Plus
Rationales | Graded Q&A Comprehensive Study Guide | (
Guaranteed Pass A+)
1. A nurse is caring for a client who is at 38 weeks of gestation and in active labor. The
client reports a sudden, severe pain in her abdomen and a tearing sensation. The fetal
monitor reveals late decelerations and fetal bradycardia. Which of the following
complications should the nurse suspect?
A. Uterine rupture
B. Placenta previa
C. Placental abruption
D. Vasa previa
Uterine rupture is a catastrophic obstetric complication characterized by sudden, severe
abdominal pain, a tearing sensation, and sudden fetal distress such as late decelerations and
bradycardia. Placenta previa typically presents with painless bright red bleeding. Placental
abruption causes dark red bleeding and constant abdominal pain, but not a tearing sensation
or rapid loss of intrauterine pressure. Vasa previa presents with painless vaginal bleeding and
fetal distress upon rupture of membranes.
2. A nurse is assessing a newborn who is 2 hours old. Which of the following findings
should the nurse report to the provider immediately?
A. Acrocyanosis of the hands and feet
B. Presence of Epstein pearls on the hard palate
C. Intercostal retractions and nasal flaring
D. A heart rate of 140/min with irregular rhythm
Intercostal retractions and nasal flaring are classic clinical indicators of respiratory distress in
a newborn and require immediate intervention. Acrocyanosis is a normal finding in a stable
newborn during the first 24 hours of life. Epstein pearls are harmless inclusion cysts commonly
found on the hard palate. A heart rate of 140/min falls within the normal newborn range of
110 to 160/min, and periodic reactivity or minor variations can occur.
3. A nurse is providing discharge instructions to a postpartum client who received the
rubella vaccine before discharge. Which of the following statements by the client indicates
an understanding of the teaching?
A. "I can try to conceive again in 1 month."
B. "I will avoid getting pregnant for at least 28 days."
C. "I should expect a mild fever and rash for the next 3 weeks."
,D. "I need to take oral antibiotics concurrently to prevent infection."
The rubella vaccine is a live-attenuated virus, and clients are advised to avoid pregnancy for
at least 28 days (or 1 to 3 months depending on institutional protocols, standard being 28
days to 3 months) to prevent teratogenic risks to a fetus. A 1-month window is often cited as
4 weeks or 28 days; however, standard guidance specifies avoiding pregnancy for 28 days to 3
months. Mild local reactions or a transient rash can occur, but avoiding pregnancy for the
specified timeframe is the critical teratogenicity precaution.
4. A nurse is caring for a client at 32 weeks of gestation who is receiving magnesium sulfate
via continuous IV infusion for preeclampsia. Which of the following findings indicates
magnesium sulfate toxicity?
A. Blood pressure of 130/80 mm Hg
B. Respiratory rate of 10/min
C. Urine output of 40 mL/hr
D. Deep tendon reflexes of 2+
A respiratory rate of less than 12/min is a primary indicator of central nervous system
depression caused by magnesium sulfate toxicity, requiring immediate cessation of the
infusion and administration of calcium gluconate. A blood pressure of 130/80 is stable. A
urine output of 40 mL/hr is adequate (greater than 30 mL/hr is expected). Deep tendon
reflexes of 2+ are normal; hyperreflexia or absent reflexes (0) indicate toxicity.
5. A nurse is monitoring a client in labor who has an epidural anesthesia block in place.
Which of the following findings is the priority nursing intervention?
A. Assess for maternal hypotension
B. Monitor for bladder distension
C. Evaluate the progress of cervical dilation
D. Check for a positive Moro reflex in the newborn
Maternal hypotension is the most common and dangerous immediate complication following
the placement of an epidural block due to sympathetic blockade causing vasodilation.
Promptly identifying and treating hypotension with IV fluids and positioning prevents
uteroplacental hypoperfusion. While bladder distension, cervical dilation, and newborn
reflexes are important, restoring and maintaining maternal blood pressure is the immediate
priority.
6. A nurse is assessing a postpartum client 12 hours after birth. The nurse notes that the
client's fundus is boggy, displaced to the right, and 2 cm above the umbilicus. Which of the
following actions should the nurse take first?
A. Administer methylergonovine as prescribed
B. Assist the client to empty her bladder
,C. Massage the fundus until firm
D. Notify the primary healthcare provider
A boggy and displaced fundus is typically caused by a distended bladder, which prevents the
uterus from contracting effectively. Assisting the client to empty her bladder is the priority
nursing action, followed by fundal massage if needed. While fundal massage and uterotonics
like methylergonovine help manage uterine atony, correcting the underlying bladder
distension resolves the displacement and allows proper contraction.
7. A nurse is caring for a newborn immediately following birth. Which of the following
nursing actions is the highest priority?
A. Administering erythromycin ophthalmic ointment
B. Drying the newborn and establishing respirations
C. Obtaining the birth weight and head circumference
D. Administering the vitamin K injection
Establishing effective respirations and preventing cold stress through thorough drying are the
immediate priorities in newborn stabilization following the ABCs of resuscitation. Prophylactic
eye ointment, vitamin K, and anthropometric measurements are important routine care items
that can be delayed until the newborn is stable and thermoregulated.
8. A nurse is caring for a client at 36 weeks of gestation who is scheduled for a nonstress
test (NST). The nurse explains that the test is nonreactive. Which of the following actions
should the nurse anticipate next?
A. Immediate induction of labor
B. Scheduling a biophysical profile (BPP) or contraction stress test (CST)
C. Discharge home with daily fetal movement counts
D. Administration of betamethasone injections
A nonreactive NST does not automatically indicate fetal compromise, but it requires further
diagnostic evaluation, such as a biophysical profile or a contraction stress test, to assess fetal
well-being. Immediate delivery is reserved for severe distress or abnormal advanced testing.
Betamethasone is used for fetal lung maturity prior to 34 weeks gestation.
9. A nurse is teaching a client who is at 10 weeks of gestation about expected physiological
changes. Which of the following statements by the client indicates a need for further
teaching?
A. "I might experience increased white vaginal discharge called leukorrhea."
B. "I should expect to feel the baby move around 12 weeks of gestation."
C. "My heart rate might increase by about 10 to 15 beats per minute."
D. "I can expect my gums to bleed more easily when I brush my teeth."
, Fetal movement, or quickening, is typically felt by a primigravida around 18 to 20 weeks of
gestation, and by a multipara around 16 to 18 weeks. Feeling movement at 12 weeks is rare
and indicates a need for correction. Leukorrhea, increased heart rate, and hyperemic bleeding
gums are expected physiological adaptations during pregnancy.
10. A nurse is caring for a client who has preeclampsia without severe features and is
managing her care at home. Which of the following instructions should the nurse
emphasize?
A. Maintain strict bed rest in the prone position
B. Rest in a left lateral recumbent position
C. Restrict fluid intake to 1,000 mL per day
D. Consume a low-protein diet to decrease renal workload
Resting in a left lateral recumbent position relieves pressure on the vena cava, improves
placental perfusion, and enhances renal blood flow. Complete bed rest is no longer routinely
recommended due to risks of thrombosis. Fluid restriction is not indicated unless pulmonary
edema develops, and protein intake should remain normal to prevent nutritional deficits.
11. A nurse is assessing a client who is 4 hours postpartum and notes a continuous trickle of
bright red vaginal blood, a firm fundus, and a normal bladder. Which of the following
conditions should the nurse suspect?
A. Uterine atony
B. Retained placental fragments
C. Laceration of the cervix or vagina
D. Uterine inversion
A continuous trickle of bright red blood in the presence of a firm, contracted uterus is the
hallmark sign of a cervical or vaginal laceration. Uterine atony presents with a boggy or soft
fundus. Retained placental fragments typically present with a boggy fundus and late
postpartum hemorrhage. Uterine inversion presents with severe pelvic pain, hemorrhage, and
an absent fundus on palpation.
12. A nurse is caring for a client who is in the transition phase of the first stage of labor.
The client states, "I cannot take this anymore, I need to push." Which of the following
actions should the nurse take?
A. Encourage the client to begin bearing down with contractions
B. Instruct the client to use panting breaths to avoid pushing
C. Prepare the delivery room for immediate birth
D. Administer an analgesic opioid medication
During the transition phase of labor, cervical dilation is 8 to 10 cm, and the client often feels
an uncontrollable urge to push. If the cervix is not fully dilated, pushing can cause cervical
