() RN Maternal Newborn ATI
Proctored Exam with Questions and Verified
Rationalized Answers, 100% Passing Score
Guarantee
1. A nurse is caring for a client who is at 38 weeks of gestation and in active
labor. The nurse observes late decelerations on the fetal heart rate monitor.
Which of the following actions should the nurse take first?
A. Administer oxygen via nonrebreather mask.
B. Reposition the client to a side-lying position.
C. Increase the IV fluid infusion rate.
D. Prepare for an immediate delivery.
Answer: B. Reposition the client to a side-lying position.
Rationale: Repositioning the client can improve uteroplacental blood flow and
resolve late decelerations. This is the priority action before implementing other
interventions.
2. A nurse is reinforcing teaching with a client about breastfeeding techniques.
Which of the following instructions should the nurse include?
A. "Hold your breast away from the baby’s mouth while feeding."
B. "Your baby should latch onto the nipple and part of the areola."
C. "Remove the baby from the breast by pulling gently on their head."
D. "Feed your baby every 6 hours during the day."
Answer: B. "Your baby should latch onto the nipple and part of the areola."
Rationale: Proper latching involves the baby grasping the nipple and part of the
areola to ensure effective feeding and prevent nipple soreness.
1
,3. A nurse is caring for a client who is at 34 weeks of gestation and has severe
preeclampsia. Which of the following findings should the nurse report to the
provider?
A. Deep tendon reflexes of 2+
B. Platelet count of 90,000/mm³
C. Blood pressure of 138/88 mm Hg
D. Proteinuria of +1
Answer: B. Platelet count of 90,000/mm³
Rationale: A low platelet count (thrombocytopenia) is a sign of worsening
preeclampsia and requires immediate intervention.
4. A nurse is assessing a newborn who is 12 hours old. Which of the following
findings should the nurse report to the provider?
A. Pink-tinged urine
B. Jaundice on the face
C. Caput succedaneum
D. Acrocyanosis
Answer: B. Jaundice on the face
Rationale: Jaundice appearing within the first 24 hours of life is abnormal and may
indicate hemolytic disease or another pathological condition.
5. A nurse is providing teaching to a client about managing nausea during
pregnancy. Which of the following client statements indicates an understanding
of the teaching?
A. "I will eat large meals to avoid feeling hungry."
B. "I should drink a glass of water before every meal."
C. "I will eat dry crackers before getting out of bed."
D. "I should lie down for 30 minutes after eating."
2
,Answer: C. "I will eat dry crackers before getting out of bed."
Rationale: Eating dry crackers before rising helps alleviate nausea associated with
morning sickness.
6. A nurse is caring for a client in the fourth stage of labor who has a saturated
perineal pad. Which of the following actions should the nurse take first?
A. Massage the fundus.
B. Administer oxytocin.
C. Assess vital signs.
D. Insert a urinary catheter.
Answer: A. Massage the fundus.
Rationale: A saturated perineal pad indicates possible uterine atony. The nurse
should first massage the fundus to stimulate uterine contractions and control
bleeding.
7. A nurse is planning care for a newborn who is receiving phototherapy for
hyperbilirubinemia. Which of the following interventions should the nurse
include?
A. Keep the newborn dressed except for a diaper.
B. Feed the newborn less frequently to promote rest.
C. Apply a thin layer of lotion to the newborn’s skin.
D. Cover the newborn’s eyes with a protective shield.
Answer: D. Cover the newborn’s eyes with a protective shield.
Rationale: The newborn’s eyes must be protected during phototherapy to prevent
retinal damage.
8. A nurse is caring for a client who is postpartum and Rh-negative. The nurse
should plan to administer Rho(D) immune globulin when which of the following
occurs?
3
, A. The client has an Rh-negative infant.
B. The client develops a positive indirect Coombs test.
C. The client has an Rh-positive infant.
D. The client experiences a postpartum hemorrhage.
Answer: C. The client has an Rh-positive infant.
Rationale: Rho(D) immune globulin is administered to an Rh-negative mother with
an Rh-positive infant to prevent Rh sensitization in future pregnancies.
9. A nurse is assessing a client who is 8 hours postpartum. Which of the
following findings should the nurse report to the provider?
A. Lochia rubra with small clots
B. Fundus firm and deviated to the right
C. Moderate perineal edema
D. Temperature of 38°C (100.4°F)
Answer: B. Fundus firm and deviated to the right
Rationale: A firm but deviated fundus suggests bladder distention, which can
interfere with uterine contraction and should be addressed promptly.
10. A nurse is teaching a client who is 28 weeks of gestation about kick counts.
Which of the following instructions should the nurse include?
A. "You should count movements twice a day for 1 hour."
B. "Notify your provider if you feel fewer than 10 movements in 2 hours."
C. "Expect fewer movements in the evening hours."
D. "A fetal heart rate monitor is required to assess movements accurately."
Answer: B. "Notify your provider if you feel fewer than 10 movements in 2 hours."
Rationale: Fewer than 10 fetal movements in 2 hours may indicate fetal distress
and should be reported to the provider for further evaluation.
11. A nurse is assessing a newborn for signs of hypoglycemia. Which of the
following findings should the nurse identify as a manifestation of hypoglycemia?
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Proctored Exam with Questions and Verified
Rationalized Answers, 100% Passing Score
Guarantee
1. A nurse is caring for a client who is at 38 weeks of gestation and in active
labor. The nurse observes late decelerations on the fetal heart rate monitor.
Which of the following actions should the nurse take first?
A. Administer oxygen via nonrebreather mask.
B. Reposition the client to a side-lying position.
C. Increase the IV fluid infusion rate.
D. Prepare for an immediate delivery.
Answer: B. Reposition the client to a side-lying position.
Rationale: Repositioning the client can improve uteroplacental blood flow and
resolve late decelerations. This is the priority action before implementing other
interventions.
2. A nurse is reinforcing teaching with a client about breastfeeding techniques.
Which of the following instructions should the nurse include?
A. "Hold your breast away from the baby’s mouth while feeding."
B. "Your baby should latch onto the nipple and part of the areola."
C. "Remove the baby from the breast by pulling gently on their head."
D. "Feed your baby every 6 hours during the day."
Answer: B. "Your baby should latch onto the nipple and part of the areola."
Rationale: Proper latching involves the baby grasping the nipple and part of the
areola to ensure effective feeding and prevent nipple soreness.
1
,3. A nurse is caring for a client who is at 34 weeks of gestation and has severe
preeclampsia. Which of the following findings should the nurse report to the
provider?
A. Deep tendon reflexes of 2+
B. Platelet count of 90,000/mm³
C. Blood pressure of 138/88 mm Hg
D. Proteinuria of +1
Answer: B. Platelet count of 90,000/mm³
Rationale: A low platelet count (thrombocytopenia) is a sign of worsening
preeclampsia and requires immediate intervention.
4. A nurse is assessing a newborn who is 12 hours old. Which of the following
findings should the nurse report to the provider?
A. Pink-tinged urine
B. Jaundice on the face
C. Caput succedaneum
D. Acrocyanosis
Answer: B. Jaundice on the face
Rationale: Jaundice appearing within the first 24 hours of life is abnormal and may
indicate hemolytic disease or another pathological condition.
5. A nurse is providing teaching to a client about managing nausea during
pregnancy. Which of the following client statements indicates an understanding
of the teaching?
A. "I will eat large meals to avoid feeling hungry."
B. "I should drink a glass of water before every meal."
C. "I will eat dry crackers before getting out of bed."
D. "I should lie down for 30 minutes after eating."
2
,Answer: C. "I will eat dry crackers before getting out of bed."
Rationale: Eating dry crackers before rising helps alleviate nausea associated with
morning sickness.
6. A nurse is caring for a client in the fourth stage of labor who has a saturated
perineal pad. Which of the following actions should the nurse take first?
A. Massage the fundus.
B. Administer oxytocin.
C. Assess vital signs.
D. Insert a urinary catheter.
Answer: A. Massage the fundus.
Rationale: A saturated perineal pad indicates possible uterine atony. The nurse
should first massage the fundus to stimulate uterine contractions and control
bleeding.
7. A nurse is planning care for a newborn who is receiving phototherapy for
hyperbilirubinemia. Which of the following interventions should the nurse
include?
A. Keep the newborn dressed except for a diaper.
B. Feed the newborn less frequently to promote rest.
C. Apply a thin layer of lotion to the newborn’s skin.
D. Cover the newborn’s eyes with a protective shield.
Answer: D. Cover the newborn’s eyes with a protective shield.
Rationale: The newborn’s eyes must be protected during phototherapy to prevent
retinal damage.
8. A nurse is caring for a client who is postpartum and Rh-negative. The nurse
should plan to administer Rho(D) immune globulin when which of the following
occurs?
3
, A. The client has an Rh-negative infant.
B. The client develops a positive indirect Coombs test.
C. The client has an Rh-positive infant.
D. The client experiences a postpartum hemorrhage.
Answer: C. The client has an Rh-positive infant.
Rationale: Rho(D) immune globulin is administered to an Rh-negative mother with
an Rh-positive infant to prevent Rh sensitization in future pregnancies.
9. A nurse is assessing a client who is 8 hours postpartum. Which of the
following findings should the nurse report to the provider?
A. Lochia rubra with small clots
B. Fundus firm and deviated to the right
C. Moderate perineal edema
D. Temperature of 38°C (100.4°F)
Answer: B. Fundus firm and deviated to the right
Rationale: A firm but deviated fundus suggests bladder distention, which can
interfere with uterine contraction and should be addressed promptly.
10. A nurse is teaching a client who is 28 weeks of gestation about kick counts.
Which of the following instructions should the nurse include?
A. "You should count movements twice a day for 1 hour."
B. "Notify your provider if you feel fewer than 10 movements in 2 hours."
C. "Expect fewer movements in the evening hours."
D. "A fetal heart rate monitor is required to assess movements accurately."
Answer: B. "Notify your provider if you feel fewer than 10 movements in 2 hours."
Rationale: Fewer than 10 fetal movements in 2 hours may indicate fetal distress
and should be reported to the provider for further evaluation.
11. A nurse is assessing a newborn for signs of hypoglycemia. Which of the
following findings should the nurse identify as a manifestation of hypoglycemia?
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