ATI Maternal Newborn Retake Exam 2023–2024
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Grade A+
ATI Maternal Newborn Retake Practice Exam (2023-2024)
1. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis
B. Respirations 66/min, irregular
C. Heart rate 106/min
D. Axillary temperature 36.1°C (97°F)
Answer: D. Axillary temperature 36.1°C (97°F)
*Rationale: A normal newborn temperature is 36.5–37.5°C (97.7–99.5°F). A temperature of
36.1°C (97°F) indicates hypothermia and requires intervention to prevent cold stress.
Acrocyanosis (blue hands and feet) is normal. Irregular respirations up to 60/min are normal;
66/min is borderline but requires monitoring. A heart rate of 106/min is within the normal range
of 110–160/min.*
,2. A client at 39 weeks gestation is admitted in active labor. Her cervix is 6 cm dilated. Two
hours later, she reports a strong urge to push. What is the nurse's first action?
A. Encourage the client to start pushing.
B. Perform a vaginal examination.
C. Administer prescribed analgesia.
D. Assist the client to the bathroom.
Answer: B. Perform a vaginal examination.
Rationale: The nurse must first assess cervical dilation. If the cervix is not fully dilated (10 cm),
pushing could cause cervical edema and tears. The urge to push can occur before full dilation
(e.g., with a fetal descending station).
3. A nurse is teaching a new mother about umbilical cord care. Which instruction is
correct?
A. Clean the cord with hydrogen peroxide every 4 hours.
B. Apply antibiotic ointment to the cord twice daily.
C. Keep the cord dry and exposed to air.
D. Sponge bathe the infant until the cord falls off.
Answer: C. Keep the cord dry and exposed to air.
Rationale: Current evidence-based practice recommends dry cord care. The cord should be kept
clean and dry to prevent infection. It should not be submerged in water, hence sponge baths are
advised. Hydrogen peroxide and antibiotic ointments are not recommended unless an infection is
present.
4. A postpartum client is receiving Methylergonovine (Methergine). Which finding
indicates a therapeutic effect?
,A. Diuresis
B. Uterine firmness
C. Pain relief
D. Decreased blood pressure
Answer: B. Uterine firmness
Rationale: Methylergonovine is an ergot alkaloid used to prevent or control postpartum
hemorrhage by causing sustained uterine contractions. Its therapeutic effect is a firm, contracted
uterus.
5. A nurse is reviewing the medical record of a client who is 12 hours postpartum. The
fundus is boggy, deviated to the right, and above the umbilicus. What is the nurse's priority
action?
A. Massage the fundus.
B. Administer a PRN analgesic.
C. Assist the client to empty her bladder.
D. Notify the provider.
Answer: C. Assist the client to empty her bladder.
Rationale: A full bladder can displace the uterus upward and to the side, preventing it from
contracting effectively and leading to a boggy fundus and hemorrhage. The first nursing action
is to assist the client to void, which should allow the uterus to return to the midline and become
firm.
6. A newborn's 1-minute Apgar score is 8. Which finding did the nurse most likely assess?
A. Blue extremities
B. Heart rate 98/min
, C. Weak cry
D. Some flexion of extremities
Answer: A. Blue extremities (Acrocyanosis)
*Rationale: An Apgar of 8 is excellent. Points are deducted for acrocyanosis (-1 on color) and
possibly for some flexion rather than full flexion (-1 on muscle tone). A heart rate below 100
would lose 1 point. A weak cry would indicate irregular respirations, losing a point.*
7. A client at 28 weeks gestation is diagnosed with gestational diabetes. Which statement by
the client indicates a need for further teaching?
A. "I will need to test my blood sugar four times a day."
B. "I can eat a small bowl of ice cream for my bedtime snack."
C. "Walking after meals will help control my blood sugar."
D. "If diet and exercise aren't enough, I may need insulin."
Answer: B. "I can eat a small bowl of ice cream for my bedtime snack."
Rationale: Simple sugars, like those in ice cream, can cause significant spikes in blood glucose.
A complex carbohydrate with a protein (like cheese and crackers) is a better choice for a
bedtime snack to prevent nocturnal hypoglycemia.
8. During a non-stress test (NST), the nurse observes two fetal heart rate (FHR)
accelerations of 15 beats per minute, each lasting 20 seconds, in a 20-minute period. How
should the nurse document this result?
A. Nonreactive
B. Reactive
C. Positive
D. Negative
| Verified Solutions & Answers | Guaranteed
Grade A+
ATI Maternal Newborn Retake Practice Exam (2023-2024)
1. A nurse is assessing a newborn 1 hour after birth. Which of the following findings should
the nurse report to the provider?
A. Acrocyanosis
B. Respirations 66/min, irregular
C. Heart rate 106/min
D. Axillary temperature 36.1°C (97°F)
Answer: D. Axillary temperature 36.1°C (97°F)
*Rationale: A normal newborn temperature is 36.5–37.5°C (97.7–99.5°F). A temperature of
36.1°C (97°F) indicates hypothermia and requires intervention to prevent cold stress.
Acrocyanosis (blue hands and feet) is normal. Irregular respirations up to 60/min are normal;
66/min is borderline but requires monitoring. A heart rate of 106/min is within the normal range
of 110–160/min.*
,2. A client at 39 weeks gestation is admitted in active labor. Her cervix is 6 cm dilated. Two
hours later, she reports a strong urge to push. What is the nurse's first action?
A. Encourage the client to start pushing.
B. Perform a vaginal examination.
C. Administer prescribed analgesia.
D. Assist the client to the bathroom.
Answer: B. Perform a vaginal examination.
Rationale: The nurse must first assess cervical dilation. If the cervix is not fully dilated (10 cm),
pushing could cause cervical edema and tears. The urge to push can occur before full dilation
(e.g., with a fetal descending station).
3. A nurse is teaching a new mother about umbilical cord care. Which instruction is
correct?
A. Clean the cord with hydrogen peroxide every 4 hours.
B. Apply antibiotic ointment to the cord twice daily.
C. Keep the cord dry and exposed to air.
D. Sponge bathe the infant until the cord falls off.
Answer: C. Keep the cord dry and exposed to air.
Rationale: Current evidence-based practice recommends dry cord care. The cord should be kept
clean and dry to prevent infection. It should not be submerged in water, hence sponge baths are
advised. Hydrogen peroxide and antibiotic ointments are not recommended unless an infection is
present.
4. A postpartum client is receiving Methylergonovine (Methergine). Which finding
indicates a therapeutic effect?
,A. Diuresis
B. Uterine firmness
C. Pain relief
D. Decreased blood pressure
Answer: B. Uterine firmness
Rationale: Methylergonovine is an ergot alkaloid used to prevent or control postpartum
hemorrhage by causing sustained uterine contractions. Its therapeutic effect is a firm, contracted
uterus.
5. A nurse is reviewing the medical record of a client who is 12 hours postpartum. The
fundus is boggy, deviated to the right, and above the umbilicus. What is the nurse's priority
action?
A. Massage the fundus.
B. Administer a PRN analgesic.
C. Assist the client to empty her bladder.
D. Notify the provider.
Answer: C. Assist the client to empty her bladder.
Rationale: A full bladder can displace the uterus upward and to the side, preventing it from
contracting effectively and leading to a boggy fundus and hemorrhage. The first nursing action
is to assist the client to void, which should allow the uterus to return to the midline and become
firm.
6. A newborn's 1-minute Apgar score is 8. Which finding did the nurse most likely assess?
A. Blue extremities
B. Heart rate 98/min
, C. Weak cry
D. Some flexion of extremities
Answer: A. Blue extremities (Acrocyanosis)
*Rationale: An Apgar of 8 is excellent. Points are deducted for acrocyanosis (-1 on color) and
possibly for some flexion rather than full flexion (-1 on muscle tone). A heart rate below 100
would lose 1 point. A weak cry would indicate irregular respirations, losing a point.*
7. A client at 28 weeks gestation is diagnosed with gestational diabetes. Which statement by
the client indicates a need for further teaching?
A. "I will need to test my blood sugar four times a day."
B. "I can eat a small bowl of ice cream for my bedtime snack."
C. "Walking after meals will help control my blood sugar."
D. "If diet and exercise aren't enough, I may need insulin."
Answer: B. "I can eat a small bowl of ice cream for my bedtime snack."
Rationale: Simple sugars, like those in ice cream, can cause significant spikes in blood glucose.
A complex carbohydrate with a protein (like cheese and crackers) is a better choice for a
bedtime snack to prevent nocturnal hypoglycemia.
8. During a non-stress test (NST), the nurse observes two fetal heart rate (FHR)
accelerations of 15 beats per minute, each lasting 20 seconds, in a 20-minute period. How
should the nurse document this result?
A. Nonreactive
B. Reactive
C. Positive
D. Negative
