ATI PN Maternal-Newborn CMS: Question
Section 1: Antepartum Nursing Care (Q1–Q25)
Q1. A pregnant client at 28 weeks gestation arrives for a routine
prenatal visit. The nurse assesses the fundal height and finds it
measuring 32 cm. Which of the following is the most appropriate
nursing action?
A. Document the finding as expected for gestational age
B. Notify the provider immediately for possible twin gestation
C. Prepare the client for an urgent ultrasound
D. Assess for signs of gestational diabetes
Answer: A
Rationale: At 28 weeks gestation, the fundal height in centimeters should
approximately equal the weeks of gestation, with a normal variance of plus
or minus 2 cm. A measurement of 32 cm at 28 weeks falls within this
acceptable range. The nurse should document the finding as within normal
limits. There is no indication for immediate provider notification, urgent
ultrasound, or gestational diabetes assessment based solely on this
finding.
Q2. A nurse is providing prenatal education to a client at 12 weeks
gestation regarding expected maternal adaptations. Which statement
by the client indicates an understanding of cardiovascular changes
during pregnancy?
A. "My blood pressure will gradually decrease during the first trimester."
B. "I should expect my heart rate to decrease by about 10 beats per
minute."
C. "My cardiac output will increase significantly to support the pregnancy."
D. "Blood volume will remain relatively stable throughout my pregnancy."
Answer: C
Rationale: During pregnancy, cardiac output increases by 30-50% to meet
the metabolic demands of the growing fetus and placenta. This increase
begins in the first trimester and peaks around 25-30 weeks gestation. Blood
,pressure typically decreases slightly during the first and second trimesters.
Heart rate increases by 10-15 beats per minute, not decreases. Blood
volume increases by 40-50% by the end of pregnancy.
Q3. A pregnant client at 24 weeks gestation with Rh-negative blood
type asks the nurse about Rho(D) immune globulin (RhoGAM). Which
response by the nurse is most appropriate?
A. "You will receive RhoGAM at 28 weeks and again within 72 hours after
delivery if your baby is Rh-positive."
B. "RhoGAM is only given if you have a miscarriage."
C. "You will need to receive RhoGAM every month during your pregnancy."
D. "RhoGAM is not necessary if this is your first pregnancy."
Answer: A
Rationale: RhoGAM is given to Rh-negative mothers at 28 weeks
gestation and within 72 hours after delivery if the newborn is Rh-positive. It
is also given after events that may cause fetal-maternal hemorrhage (e.g.,
miscarriage, amniocentesis). It is not given monthly, and it is necessary
even in a first pregnancy to prevent sensitization.
Q4. A nurse is providing nutritional teaching for a pregnant client who
had a prepregnancy body mass index (BMI) of 38. Which of the
following statements by the client demonstrates an understanding of
the teaching about her recommended weight gain during pregnancy?
A. "I should plan to gain 12.7 to 18.1 kg during my pregnancy."
B. "I should plan to gain 11.3 to 15.9 kg during my pregnancy."
C. "I should plan to gain 6.8 to 11.3 kg during my pregnancy."
D. "I should plan to gain 5 to 9.1 kg during my pregnancy."
Answer: D
Rationale: For a client with a prepregnancy BMI of 38 (obese), the
recommended weight gain during pregnancy is 5 to 9.1 kg (11 to 20 lb).
,Q5. A nurse is teaching a client who has active genital herpes simplex
virus, type 2. Which of the following statements should the nurse
include in the teaching?
A. "You will have a cesarean birth prior to the onset of labor."
B. "Your baby will receive erythromycin eye ointment after birth to treat the
infection."
C. "You should take oral metronidazole for 7 days prior to 37 weeks
gestation."
D. "You should schedule a cesarean birth after your water breaks."
Answer: A
Rationale: To prevent neonatal herpes infection, a cesarean birth is
recommended for clients with active genital herpes lesions at the time of
labor. The cesarean should be performed prior to the onset of labor or
within 4 hours of membrane rupture.
Q6. A nurse is discussing the expected changes related to pregnancy
with a client who is at 8 weeks gestation. Which of the following
findings should the client report to the provider during the first
trimester?
A. Breast tenderness
B. Urinary frequency
C. Persistent vomiting
D. No fetal movement
Answer: C
Rationale: Persistent vomiting in the first trimester may indicate
hyperemesis gravidarum, which requires medical evaluation and treatment.
Breast tenderness and urinary frequency are normal adaptations of
pregnancy. Fetal movement is not expected until 16-20 weeks gestation.
Q7. A nurse is providing counseling for a couple experiencing
infertility issues. Which of the following statements by the nurse is
appropriate?
, A. "Even though you can't have children biologically, you can always adopt
a child."
B. "You need to take a break from these attempts to conceive."
C. "You might want to join our support group for couples who are
experiencing similar problems."
D. "Why didn't you get your immunizations when you were younger?"
Answer: C
Rationale: Offering a support group is a therapeutic and appropriate
response that provides resources without offering false reassurance or
asking intrusive questions.
Q8. A nurse is teaching a client who is pregnant and has
pregestational diabetes about dietary changes. Which of the following
statements should the nurse include in the teaching?
A. "Carbohydrates should make up 55% of your diet."
B. "Protein should make up 70% of your diet."
C. "Fats should make up 45% of your diet."
D. "Fiber should make up 10% of your diet."
Answer: A
Rationale: For clients with pregestational diabetes, a balanced diet is
recommended with carbohydrates making up approximately 50-55% of
daily caloric intake, protein 20%, and fats 25-30%.
Q9. A nurse is caring for a client who is at 36 weeks of gestation and
has preeclampsia. Which finding should the nurse report to the
provider immediately?
A. Blood pressure 140/90 mm Hg
B. 1+ proteinuria
C. Severe headache unrelieved by acetaminophen
D. Mild ankle edema
Section 1: Antepartum Nursing Care (Q1–Q25)
Q1. A pregnant client at 28 weeks gestation arrives for a routine
prenatal visit. The nurse assesses the fundal height and finds it
measuring 32 cm. Which of the following is the most appropriate
nursing action?
A. Document the finding as expected for gestational age
B. Notify the provider immediately for possible twin gestation
C. Prepare the client for an urgent ultrasound
D. Assess for signs of gestational diabetes
Answer: A
Rationale: At 28 weeks gestation, the fundal height in centimeters should
approximately equal the weeks of gestation, with a normal variance of plus
or minus 2 cm. A measurement of 32 cm at 28 weeks falls within this
acceptable range. The nurse should document the finding as within normal
limits. There is no indication for immediate provider notification, urgent
ultrasound, or gestational diabetes assessment based solely on this
finding.
Q2. A nurse is providing prenatal education to a client at 12 weeks
gestation regarding expected maternal adaptations. Which statement
by the client indicates an understanding of cardiovascular changes
during pregnancy?
A. "My blood pressure will gradually decrease during the first trimester."
B. "I should expect my heart rate to decrease by about 10 beats per
minute."
C. "My cardiac output will increase significantly to support the pregnancy."
D. "Blood volume will remain relatively stable throughout my pregnancy."
Answer: C
Rationale: During pregnancy, cardiac output increases by 30-50% to meet
the metabolic demands of the growing fetus and placenta. This increase
begins in the first trimester and peaks around 25-30 weeks gestation. Blood
,pressure typically decreases slightly during the first and second trimesters.
Heart rate increases by 10-15 beats per minute, not decreases. Blood
volume increases by 40-50% by the end of pregnancy.
Q3. A pregnant client at 24 weeks gestation with Rh-negative blood
type asks the nurse about Rho(D) immune globulin (RhoGAM). Which
response by the nurse is most appropriate?
A. "You will receive RhoGAM at 28 weeks and again within 72 hours after
delivery if your baby is Rh-positive."
B. "RhoGAM is only given if you have a miscarriage."
C. "You will need to receive RhoGAM every month during your pregnancy."
D. "RhoGAM is not necessary if this is your first pregnancy."
Answer: A
Rationale: RhoGAM is given to Rh-negative mothers at 28 weeks
gestation and within 72 hours after delivery if the newborn is Rh-positive. It
is also given after events that may cause fetal-maternal hemorrhage (e.g.,
miscarriage, amniocentesis). It is not given monthly, and it is necessary
even in a first pregnancy to prevent sensitization.
Q4. A nurse is providing nutritional teaching for a pregnant client who
had a prepregnancy body mass index (BMI) of 38. Which of the
following statements by the client demonstrates an understanding of
the teaching about her recommended weight gain during pregnancy?
A. "I should plan to gain 12.7 to 18.1 kg during my pregnancy."
B. "I should plan to gain 11.3 to 15.9 kg during my pregnancy."
C. "I should plan to gain 6.8 to 11.3 kg during my pregnancy."
D. "I should plan to gain 5 to 9.1 kg during my pregnancy."
Answer: D
Rationale: For a client with a prepregnancy BMI of 38 (obese), the
recommended weight gain during pregnancy is 5 to 9.1 kg (11 to 20 lb).
,Q5. A nurse is teaching a client who has active genital herpes simplex
virus, type 2. Which of the following statements should the nurse
include in the teaching?
A. "You will have a cesarean birth prior to the onset of labor."
B. "Your baby will receive erythromycin eye ointment after birth to treat the
infection."
C. "You should take oral metronidazole for 7 days prior to 37 weeks
gestation."
D. "You should schedule a cesarean birth after your water breaks."
Answer: A
Rationale: To prevent neonatal herpes infection, a cesarean birth is
recommended for clients with active genital herpes lesions at the time of
labor. The cesarean should be performed prior to the onset of labor or
within 4 hours of membrane rupture.
Q6. A nurse is discussing the expected changes related to pregnancy
with a client who is at 8 weeks gestation. Which of the following
findings should the client report to the provider during the first
trimester?
A. Breast tenderness
B. Urinary frequency
C. Persistent vomiting
D. No fetal movement
Answer: C
Rationale: Persistent vomiting in the first trimester may indicate
hyperemesis gravidarum, which requires medical evaluation and treatment.
Breast tenderness and urinary frequency are normal adaptations of
pregnancy. Fetal movement is not expected until 16-20 weeks gestation.
Q7. A nurse is providing counseling for a couple experiencing
infertility issues. Which of the following statements by the nurse is
appropriate?
, A. "Even though you can't have children biologically, you can always adopt
a child."
B. "You need to take a break from these attempts to conceive."
C. "You might want to join our support group for couples who are
experiencing similar problems."
D. "Why didn't you get your immunizations when you were younger?"
Answer: C
Rationale: Offering a support group is a therapeutic and appropriate
response that provides resources without offering false reassurance or
asking intrusive questions.
Q8. A nurse is teaching a client who is pregnant and has
pregestational diabetes about dietary changes. Which of the following
statements should the nurse include in the teaching?
A. "Carbohydrates should make up 55% of your diet."
B. "Protein should make up 70% of your diet."
C. "Fats should make up 45% of your diet."
D. "Fiber should make up 10% of your diet."
Answer: A
Rationale: For clients with pregestational diabetes, a balanced diet is
recommended with carbohydrates making up approximately 50-55% of
daily caloric intake, protein 20%, and fats 25-30%.
Q9. A nurse is caring for a client who is at 36 weeks of gestation and
has preeclampsia. Which finding should the nurse report to the
provider immediately?
A. Blood pressure 140/90 mm Hg
B. 1+ proteinuria
C. Severe headache unrelieved by acetaminophen
D. Mild ankle edema
