ATI Maternal Newborn Proctored Exam with answers and evidence-based rationales.

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ATI Maternal Newborn Proctored Exam with answers and
evidence-based rationales.


1. A nurse is assessing a full-term newborn immediately after delivery. Which of
the following findings is expected and requires no intervention?
 A. Heart rate of 90 bpm
 B. Acrocyanosis of hands and feet
 C. Absence of Moro reflex
 D. Respiratory rate of 10 breaths/min
Correct Answer: B
Rationale: Acrocyanosis (bluish discoloration of hands and feet) is normal in the
first 24–48 hours after birth due to immature peripheral circulation. Heart rate
should be 110–160 bpm; 90 bpm is bradycardic. Moro reflex should be present at
birth. Respiratory rate should be 30–60 breaths/min; 10 is severely depressed.


Additional Questions (99 more)
2. A nurse is caring for a client at 38 weeks gestation who reports a sudden gush
of fluid from the vagina. Which action should the nurse take first?
 A. Check cervical dilation
 B. Assess fetal heart rate
 C. Test fluid with nitrazine paper
 D. Encourage ambulation
Answer: B – Ensuring fetal well-being is priority; assess for cord prolapse or
distress after rupture of membranes.

,3. A newborn has Apgar scores of 6 at 1 minute and 8 at 5 minutes. Which
interpretation is correct?
 A. Severe distress
 B. Moderate distress improving
 C. Normal transition
 D. No resuscitation needed
Answer: B – 6 indicates moderate distress; improvement to 8 shows good
response.
4. A nurse teaches a postpartum client about signs of infection. Which
statement indicates understanding?
 A. "I'll call if my lochia changes from red to pink."
 B. "Fever over 100.4°F is normal for first 2 days."
 C. "Uterine tenderness with foul lochia needs reporting."
 D. "Increased bleeding is expected with breastfeeding."
Answer: C – Foul lochia and uterine tenderness suggest endometritis; requires
prompt treatment.
5. A nurse administers vitamin K intramuscularly to a newborn. What is the
purpose?
 A. Prevent ophthalmia neonatorum
 B. Promote bilirubin conjugation
 C. Prevent hemorrhagic disease of newborn
 D. Enhance immune function
Answer: C – Newborns have sterile guts and lack vitamin K-dependent clotting
factors.
6. A client at 32 weeks with preterm labor receives betamethasone. The nurse
explains this drug:

,  A. Stops uterine contractions
 B. Accelerates fetal lung maturity
 C. Prevents neonatal infection
 D. Reduces maternal blood pressure
Answer: B – Betamethasone promotes surfactant production to reduce
respiratory distress syndrome.
7. A nurse assesses a postpartum woman 2 hours after vaginal delivery. Fundus
is boggy and deviated to the right. Which action first?
 A. Document findings
 B. Massage fundus
 C. Assist client to void
 D. Administer oxytocin
Answer: C – A distended bladder displaces the uterus; after voiding, reassess and
massage if still boggy.
8. A newborn is jaundiced at 12 hours of life. Which cause should the nurse
suspect?
 A. Physiologic jaundice
 B. Breastfeeding jaundice
 C. Pathologic jaundice
 D. Breast milk jaundice
Answer: C – Jaundice within first 24 hours is pathologic (e.g., hemolytic disease)
until ruled out.
9. A nurse notes late decelerations on fetal monitor. Which action is priority?
 A. Increase IV fluids
 B. Turn client to left lateral position
 C. Administer oxygen at 2 L/min

,  D. Prepare for immediate delivery
Answer: B – Late decels indicate uteroplacental insufficiency; left lateral improves
placental flow.
10. A G1P0 client at 40 weeks has contractions every 3–4 minutes, cervix 5
cm/90%/-1. Which stage of labor?
 A. Latent first stage
 B. Active first stage
 C. Transition
 D. Second stage
Answer: B – Active phase: 4–7 cm dilation with moderate to strong contractions.
11. Which finding in a 1-hour-old newborn requires immediate intervention?
 A. Grunting with nasal flaring
 B. Irregular breathing rate of 50/min
 C. Periodic breathing lasting 5 seconds
 D. Heart rate of 150 bpm
Answer: A – Grunting with nasal flaring indicates respiratory distress; needs
evaluation.
12. A nurse performs a heel stick on a newborn for glucose. The reading is 35
mg/dL. What action?
 A. Recheck in 2 hours
 B. Feed the newborn immediately
 C. Notify the provider for IV dextrose
 D. Document as normal
Answer: B – Newborn hypoglycemia is <40–45 mg/dL; early feeding is first-line
treatment.
13. Which maternal condition is a contraindication for breastfeeding?