2025/2026 ATI RN MATERNAL NEWBORN
EXAMINATION/GRADED A+
Exhibit 1: Medical hx
Newborn delivered by repeat cesarean birth at 40 weeks of gestation. Birth
weight 3,515 g (7 lb 12 oz) Apgar scores 8 at 1 min and 9 at 5 min. Maternal
history of methadone use during pregnancy.
Exhibit 2: VS
@0700: Heart rate 156/min. Respiratory rate 58/min. Temperature 37.2° C
(98.9° F) Oxygen saturation 98% on room air
@1100: Heart rate 160/min. Respiratory rate 60/min. Temperature 37.3° C
(99.2° F) Oxygen saturation 96% on room air
Exhibit 3: Phys Exam
Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously
on pacifier but breastfeeds poorly. Respirations unlabored. Lungs sound clear
on auscultation. Increased muscle tone with moderate to severe tremors when
disturbed. Hyperactive Moro reflex noted. Several loose stools today.
Exhibit 4: Diagnostic Results
Maternal urine toxicology screen positive for opiates (-). Newborn urine
toxicology screen positive for opiates (- - ANSWER-Respiratory findings is
incorrect. The newborn's respiratory rate is within the expected reference
range of 30 to 60/min. There is no indication the newborn has an alteration in
respiratory status; therefore, this finding does not need to be reported to the
provider.
,Temperature is incorrect. The newborn's temperature is within the expected
reference range of 36.5° to 37.5° C (97.7° to 99.5° F). Therefore, this finding
does not need to be reported to the provider.
Oxygen saturation is incorrect. The newborn's oxygen saturation is within the
expected reference range of greater than 94%; therefore, this finding does not
need to be reported to the provider.
Central nervous system findings is correct. The newborn is displaying
inconsolability, high-pitched cry, increased muscle tone, tremors, hyperactive
Moro reflex, and excessive sucking. These findings are manifestations of NAS
and should be reported to the provider.
Gastrointestinal findings is correct. The newborn is displaying poor feeding
and loose stools. These findings are manifestations of NAS and should be
reported to the provider.
Exhibit 1: RN note
@ 0900: Client reports a small amount of bright red blood in their underwear
upon awakening. Client denies contractions or abdominal pain. External fetal
monitor applied.
@0930: Client passed large amount of bright red blood from vagina. Denies
pain. Uterine tone soft and nontender to palpation. Contraction pattern: no
contractions noted. Fetal heart rate pattern: Fetal heart rate baseline 135/min.
Moderate variability. No decelerations noted.
Exhibit 2: VS
@0900: Temperature 36.2°C (97.2° F)Pulse rate 78/min. Respiratory rate
20/min. Blood pressure 112/64 mmHg. Fetal heart rate 132/min
@0930: Pulse rate 82/min. Blood pressure 116/60 mmHg. Fetal heart rate
160/min
Exhibit 3: Medical hx
,G4P3. 30 weeks gestation. Previous pregnancies delivered via cesarean section
- ANSWER-When generating solutions, inserting a large bore intravenous
catheter is indicated. Clients who have third trimester vaginal bleeding may
experience a sudden hemorrhage and require fluid resuscitation or the
administration of blood products. The nurse should weigh perineal pads.
Weighing perineal pads after use will provide a more accurate assessment of
the volume of blood loss that the client is experiencing.
When generating solutions, the nurse should not administer methotrexate or
assess for cervical dilation because it is contraindicated for this client.
Methotrexate is an antimetabolite and folic acid antagonist which destroys
rapidly dividing cells. It can be administered during pregnancy to medically
resolve an ectopic pregnancy during the first trimester. Assessing cervical
dilation is contraindicated for any pregnant client who is experiencing vaginal
bleeding. Manipulation of the cervix during the examination may result in
further damage to the placenta and compromise the well-being of the client
and fetus.
A nurse is assessing the newborn of a client who took selective serotonin
reuptake inhibitor (SSRI) during pregnancy. Which of the following
manifestations should the nurse identify as an indication of withdrawal from
an SSRI?
a. Large for gestational age
b. Hyperglycemia
c. Bradypnea
d. Vomiting - ANSWER-d. Vomiting
Expected manifestations associated with fetal exposure to SSRIs include
irritability, agitation, tremors, diarrhea, and vomiting. These manifestations
typically last 2 days.
, A nurse in a family planning clinic is caring for a client who requests an oral
contraceptive. Which of the following findings in the client's history should
the nurse recognize as a contraindication to oral contraceptives? (Select all
that apply)
a. Cholecystitis
b. Hypertension
c. Human papillomavirus
d. Migraine headaches
e. Anxiety disorder - ANSWER-Cholecystitis, hypertension, and migraine
headaches is correct. A history of gallbladder disease is a contraindication for
the use of oral contraceptives. Hypertension is a contraindication for the use
of oral contraceptives. A history of migraine headaches is a contraindication
for the use of oral contraceptives.
HPV and anxiety disorder is incorrect. The presence of human papillomavirus
is not a contraindication for the use of oral contraceptives. The presence of an
anxiety disorder is not a contraindication for the use of oral contraceptives.
A nurse is caring for a newborn.
Exhibit 1: Medical hx
@1600: Apgar score 9 at 1 min and 9 at 5 min. Birth weight 4,706g (10lb 6oz).
Gestational age 40 weeks. Difficult vaginal birth with shoulder dystocia.
Exhibit 2: RN note
EXAMINATION/GRADED A+
Exhibit 1: Medical hx
Newborn delivered by repeat cesarean birth at 40 weeks of gestation. Birth
weight 3,515 g (7 lb 12 oz) Apgar scores 8 at 1 min and 9 at 5 min. Maternal
history of methadone use during pregnancy.
Exhibit 2: VS
@0700: Heart rate 156/min. Respiratory rate 58/min. Temperature 37.2° C
(98.9° F) Oxygen saturation 98% on room air
@1100: Heart rate 160/min. Respiratory rate 60/min. Temperature 37.3° C
(99.2° F) Oxygen saturation 96% on room air
Exhibit 3: Phys Exam
Newborn is inconsolable with a high-pitched cry. Newborn sucks vigorously
on pacifier but breastfeeds poorly. Respirations unlabored. Lungs sound clear
on auscultation. Increased muscle tone with moderate to severe tremors when
disturbed. Hyperactive Moro reflex noted. Several loose stools today.
Exhibit 4: Diagnostic Results
Maternal urine toxicology screen positive for opiates (-). Newborn urine
toxicology screen positive for opiates (- - ANSWER-Respiratory findings is
incorrect. The newborn's respiratory rate is within the expected reference
range of 30 to 60/min. There is no indication the newborn has an alteration in
respiratory status; therefore, this finding does not need to be reported to the
provider.
,Temperature is incorrect. The newborn's temperature is within the expected
reference range of 36.5° to 37.5° C (97.7° to 99.5° F). Therefore, this finding
does not need to be reported to the provider.
Oxygen saturation is incorrect. The newborn's oxygen saturation is within the
expected reference range of greater than 94%; therefore, this finding does not
need to be reported to the provider.
Central nervous system findings is correct. The newborn is displaying
inconsolability, high-pitched cry, increased muscle tone, tremors, hyperactive
Moro reflex, and excessive sucking. These findings are manifestations of NAS
and should be reported to the provider.
Gastrointestinal findings is correct. The newborn is displaying poor feeding
and loose stools. These findings are manifestations of NAS and should be
reported to the provider.
Exhibit 1: RN note
@ 0900: Client reports a small amount of bright red blood in their underwear
upon awakening. Client denies contractions or abdominal pain. External fetal
monitor applied.
@0930: Client passed large amount of bright red blood from vagina. Denies
pain. Uterine tone soft and nontender to palpation. Contraction pattern: no
contractions noted. Fetal heart rate pattern: Fetal heart rate baseline 135/min.
Moderate variability. No decelerations noted.
Exhibit 2: VS
@0900: Temperature 36.2°C (97.2° F)Pulse rate 78/min. Respiratory rate
20/min. Blood pressure 112/64 mmHg. Fetal heart rate 132/min
@0930: Pulse rate 82/min. Blood pressure 116/60 mmHg. Fetal heart rate
160/min
Exhibit 3: Medical hx
,G4P3. 30 weeks gestation. Previous pregnancies delivered via cesarean section
- ANSWER-When generating solutions, inserting a large bore intravenous
catheter is indicated. Clients who have third trimester vaginal bleeding may
experience a sudden hemorrhage and require fluid resuscitation or the
administration of blood products. The nurse should weigh perineal pads.
Weighing perineal pads after use will provide a more accurate assessment of
the volume of blood loss that the client is experiencing.
When generating solutions, the nurse should not administer methotrexate or
assess for cervical dilation because it is contraindicated for this client.
Methotrexate is an antimetabolite and folic acid antagonist which destroys
rapidly dividing cells. It can be administered during pregnancy to medically
resolve an ectopic pregnancy during the first trimester. Assessing cervical
dilation is contraindicated for any pregnant client who is experiencing vaginal
bleeding. Manipulation of the cervix during the examination may result in
further damage to the placenta and compromise the well-being of the client
and fetus.
A nurse is assessing the newborn of a client who took selective serotonin
reuptake inhibitor (SSRI) during pregnancy. Which of the following
manifestations should the nurse identify as an indication of withdrawal from
an SSRI?
a. Large for gestational age
b. Hyperglycemia
c. Bradypnea
d. Vomiting - ANSWER-d. Vomiting
Expected manifestations associated with fetal exposure to SSRIs include
irritability, agitation, tremors, diarrhea, and vomiting. These manifestations
typically last 2 days.
, A nurse in a family planning clinic is caring for a client who requests an oral
contraceptive. Which of the following findings in the client's history should
the nurse recognize as a contraindication to oral contraceptives? (Select all
that apply)
a. Cholecystitis
b. Hypertension
c. Human papillomavirus
d. Migraine headaches
e. Anxiety disorder - ANSWER-Cholecystitis, hypertension, and migraine
headaches is correct. A history of gallbladder disease is a contraindication for
the use of oral contraceptives. Hypertension is a contraindication for the use
of oral contraceptives. A history of migraine headaches is a contraindication
for the use of oral contraceptives.
HPV and anxiety disorder is incorrect. The presence of human papillomavirus
is not a contraindication for the use of oral contraceptives. The presence of an
anxiety disorder is not a contraindication for the use of oral contraceptives.
A nurse is caring for a newborn.
Exhibit 1: Medical hx
@1600: Apgar score 9 at 1 min and 9 at 5 min. Birth weight 4,706g (10lb 6oz).
Gestational age 40 weeks. Difficult vaginal birth with shoulder dystocia.
Exhibit 2: RN note
