Maternity/Newborn ATI Questions and
Answers | Latest Version | 2025/2026 |
Correct & Verified
A nurse is caring for a client in labor who is receiving oxytocin. The fetal heart rate shows late
decelerations. What is the nurse’s priority action?
✔✔Discontinue the oxytocin infusion immediately.
A nurse is assessing a newborn 2 hours after birth. The newborn has acrocyanosis and is crying
vigorously. What should the nurse do?
✔✔Document the findings as normal for this age.
A client at 36 weeks gestation reports sudden gush of fluid from the vagina. What is the nurse’s
first action?
✔✔Check the fetal heart rate.
A nurse is caring for a client who is 3 hours postpartum with a boggy uterus. What is the priority
nursing action?
✔✔Massage the fundus until it becomes firm.
1
,A newborn has a respiratory rate of 68 breaths per minute and nasal flaring. What should the
nurse do?
✔✔Notify the provider of signs of respiratory distress.
A nurse is caring for a client who is breastfeeding and reports cracked nipples. What is the best
nursing intervention?
✔✔Ensure the infant is latching deeply onto the areola.
A client in labor is having contractions every 2 minutes lasting 90 seconds with minimal rest
between. What is the priority action?
✔✔Stop oxytocin and notify the provider due to uterine tachysystole.
A nurse is teaching a client about signs of true labor. What should the nurse include?
✔✔Contractions become stronger, more regular, and increase with activity.
A nurse is assessing a newborn and notes a positive Babinski reflex. What should the nurse do?
✔✔Document the finding as normal in a newborn.
2
,A client at 38 weeks reports decreased fetal movement. What is the priority nursing action?
✔✔Instruct the client to come to the facility for further evaluation.
A nurse is caring for a postpartum client with a saturated perineal pad within 15 minutes. What is
the priority nursing intervention?
✔✔Assess the fundus for firmness and location.
A newborn is placed under a radiant warmer after delivery. What is the primary reason for this
intervention?
✔✔To prevent cold stress and hypoglycemia.
A nurse is caring for a client who received magnesium sulfate. Which assessment requires
immediate action?
✔✔Respiratory rate of 10 breaths per minute.
A nurse is teaching about car seat safety. What should the nurse include in the teaching?
✔✔Place the infant rear-facing in the back seat of the vehicle.
3
, A client is Rh-negative and has just delivered an Rh-positive newborn. What is the priority
action?
✔✔Administer Rho(D) immune globulin within 72 hours.
A nurse is caring for a client experiencing late decelerations during labor. What is the initial
nursing intervention?
✔✔Reposition the client to her side.
A client in the third trimester reports persistent headaches and blurred vision. What condition
should the nurse suspect?
✔✔Preeclampsia.
A nurse is teaching a postpartum client about preventing breast engorgement. What instruction
should be included?
✔✔Apply cold compresses and wear a supportive bra if not breastfeeding.
A nurse is caring for a newborn with a blood glucose of 38 mg/dL. What is the nurse’s priority
action?
✔✔Feed the newborn immediately to raise glucose levels.
4
Answers | Latest Version | 2025/2026 |
Correct & Verified
A nurse is caring for a client in labor who is receiving oxytocin. The fetal heart rate shows late
decelerations. What is the nurse’s priority action?
✔✔Discontinue the oxytocin infusion immediately.
A nurse is assessing a newborn 2 hours after birth. The newborn has acrocyanosis and is crying
vigorously. What should the nurse do?
✔✔Document the findings as normal for this age.
A client at 36 weeks gestation reports sudden gush of fluid from the vagina. What is the nurse’s
first action?
✔✔Check the fetal heart rate.
A nurse is caring for a client who is 3 hours postpartum with a boggy uterus. What is the priority
nursing action?
✔✔Massage the fundus until it becomes firm.
1
,A newborn has a respiratory rate of 68 breaths per minute and nasal flaring. What should the
nurse do?
✔✔Notify the provider of signs of respiratory distress.
A nurse is caring for a client who is breastfeeding and reports cracked nipples. What is the best
nursing intervention?
✔✔Ensure the infant is latching deeply onto the areola.
A client in labor is having contractions every 2 minutes lasting 90 seconds with minimal rest
between. What is the priority action?
✔✔Stop oxytocin and notify the provider due to uterine tachysystole.
A nurse is teaching a client about signs of true labor. What should the nurse include?
✔✔Contractions become stronger, more regular, and increase with activity.
A nurse is assessing a newborn and notes a positive Babinski reflex. What should the nurse do?
✔✔Document the finding as normal in a newborn.
2
,A client at 38 weeks reports decreased fetal movement. What is the priority nursing action?
✔✔Instruct the client to come to the facility for further evaluation.
A nurse is caring for a postpartum client with a saturated perineal pad within 15 minutes. What is
the priority nursing intervention?
✔✔Assess the fundus for firmness and location.
A newborn is placed under a radiant warmer after delivery. What is the primary reason for this
intervention?
✔✔To prevent cold stress and hypoglycemia.
A nurse is caring for a client who received magnesium sulfate. Which assessment requires
immediate action?
✔✔Respiratory rate of 10 breaths per minute.
A nurse is teaching about car seat safety. What should the nurse include in the teaching?
✔✔Place the infant rear-facing in the back seat of the vehicle.
3
, A client is Rh-negative and has just delivered an Rh-positive newborn. What is the priority
action?
✔✔Administer Rho(D) immune globulin within 72 hours.
A nurse is caring for a client experiencing late decelerations during labor. What is the initial
nursing intervention?
✔✔Reposition the client to her side.
A client in the third trimester reports persistent headaches and blurred vision. What condition
should the nurse suspect?
✔✔Preeclampsia.
A nurse is teaching a postpartum client about preventing breast engorgement. What instruction
should be included?
✔✔Apply cold compresses and wear a supportive bra if not breastfeeding.
A nurse is caring for a newborn with a blood glucose of 38 mg/dL. What is the nurse’s priority
action?
✔✔Feed the newborn immediately to raise glucose levels.
4
