ATI 2023 MATERNAL NEWBORN TEST A & B ACTUAL
EXAM | COMPREHENSIVE PRACTICE QUESTIONS &
RATIONALES FOR NURSING EXAM
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.
Which should the Nurse report?
Respiratory findings
Temperature
Oxygen saturation
Central nervous system findings
Gastrointestinal findings - ANS✔✔-Gastrointestinal findings
Central nervous system findings
Client reports a small amount of bright red blood in their underwear upon awakening. Client denies
contractions or abdominal pain.
External fetal monitor applied.
Potential Nursing Action
Indicated or Contraindicated
Assess cervical dilation
Weigh perineal pads.
Administer methotrexate.
Insert a large bore intravenous catheter. - ANS✔✔-Contraindicated
Assess Cervical Dilation - She's currently bleeding and not in the middle of labor, unnecessary.
Administer Methotrexate - She isn't having an ectopic pregnancy - this is used to resolve ectopic
pregnancies in the first trimester.
Indicated
Weigh Perineal Pads - We need to know how much blood she's losing.
Insert a large bore IV - Third Trimester Bleeding may lead to larger hemorrhage - having IV access is critical
if we need to administer fluids.
A nurse is assessing the newborn of a client who took selective serotonin reuptake inhibitor during
pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal
from an SSRI? - ANS✔✔-Vomiting - Also could be irritability, agitation, tremors, or diarrhea. These
manifestations typically last 2 days.
A nurse in a family planning clinic is caring for a client who request an oral
contraceptive. Which of the following findings in the clients history show the nurse
recognized as a contraindication to oral contraceptives. select all that apply
Cholecystitis
Hypertension
Human papillomavirus
Migraine headaches
Anxiety disorder - ANS✔✔-Cholecystitis
Hypertension
Anxiety disorder
1/9
, A nurse is caring for a newborn.Medical History
1600:Apgar Score 9 at 1 min and 9 at 5 min
Birth weight 10 lb 6 oz (4706 gm)
Gestational age 40 weeks
Difficult vaginal birth with shoulder dystocia. - ANS✔✔-Indicated:
Educate the parents to begin ROM exercises on the affected arm after 1 week. - ROM help restore
functionality. Delay 1 week to prevent additional injury to brachial plexus.
Assess for grasp reflex in the affected extremity. - With Erb's Palsy (Erb-Duchenne) only the upper arm is
affected. Wrist and finger function should NOT be affected.
Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt. - This will assist int
he healing process.
A nurse is admitting a client to the labor and delivery unit when the client states, "my water just broke",
which of the following is the priority intervention for the nurse to take? - ANS✔✔-Begin FHR Monitoring -
The greatest risk to the client and their fetus following a rupture of membranes is an umbilical cord prolapse.
FHR is the PRIORITY action.
A nurse in an antepartum clinic is providing care for a client who is at 26 weeks gestation. Upon reviewing
the clients medical record, what findings should the nurse report to the provider?
1-hr Glucose of 130 to 140 (or greater) indicates a positive test.
Hematocrit of 34% is within range - should be greater than 33%.
FHR - Should be between 110/min to 160/min for a client at 26 weeks of gestation. - ANS✔✔-Fundal height
30 cm - Fundal height should be PLUS or MINUS 2cm from weeks of gestation
A nurse is caring for a newborn who is 48 hr old.
Apgars: 7 at 1 min and 8 at 5 min of age
Birth weight: 3,515 g (7 lb 12 oz)
Maternal blood type: O+
Uncomplicated pregnancy.
Maternal use of marijuana during pregnancy
Client who gave birth plans to breastfeed.
Day 2, 0900:
Newborn awake, alert, and crying. Loosely<<<< wrapped in one blanket. Mild tremors noted. Yellow
discoloration of mucus membranes and sclera noted. Respirations 88/min, no retractions, grunting, or nasal
flaring noted. Diaper changed for small amount of urine and transitional stool.
Day 2, 0915:Blood glucose: 38 mg/dL (expected value greater than 40 to 45 gm/dL
Potential Condition? - It's NOT NAS since Mom wasn't on opiates. It's NOT Bilirubin issues so no
phototherapy. None of the babies S/S point to Respiratory distress either.
COLD STRESS
2/9
EXAM | COMPREHENSIVE PRACTICE QUESTIONS &
RATIONALES FOR NURSING EXAM
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.
Which should the Nurse report?
Respiratory findings
Temperature
Oxygen saturation
Central nervous system findings
Gastrointestinal findings - ANS✔✔-Gastrointestinal findings
Central nervous system findings
Client reports a small amount of bright red blood in their underwear upon awakening. Client denies
contractions or abdominal pain.
External fetal monitor applied.
Potential Nursing Action
Indicated or Contraindicated
Assess cervical dilation
Weigh perineal pads.
Administer methotrexate.
Insert a large bore intravenous catheter. - ANS✔✔-Contraindicated
Assess Cervical Dilation - She's currently bleeding and not in the middle of labor, unnecessary.
Administer Methotrexate - She isn't having an ectopic pregnancy - this is used to resolve ectopic
pregnancies in the first trimester.
Indicated
Weigh Perineal Pads - We need to know how much blood she's losing.
Insert a large bore IV - Third Trimester Bleeding may lead to larger hemorrhage - having IV access is critical
if we need to administer fluids.
A nurse is assessing the newborn of a client who took selective serotonin reuptake inhibitor during
pregnancy. Which of the following manifestations should the nurse identify as an indication of withdrawal
from an SSRI? - ANS✔✔-Vomiting - Also could be irritability, agitation, tremors, or diarrhea. These
manifestations typically last 2 days.
A nurse in a family planning clinic is caring for a client who request an oral
contraceptive. Which of the following findings in the clients history show the nurse
recognized as a contraindication to oral contraceptives. select all that apply
Cholecystitis
Hypertension
Human papillomavirus
Migraine headaches
Anxiety disorder - ANS✔✔-Cholecystitis
Hypertension
Anxiety disorder
1/9
, A nurse is caring for a newborn.Medical History
1600:Apgar Score 9 at 1 min and 9 at 5 min
Birth weight 10 lb 6 oz (4706 gm)
Gestational age 40 weeks
Difficult vaginal birth with shoulder dystocia. - ANS✔✔-Indicated:
Educate the parents to begin ROM exercises on the affected arm after 1 week. - ROM help restore
functionality. Delay 1 week to prevent additional injury to brachial plexus.
Assess for grasp reflex in the affected extremity. - With Erb's Palsy (Erb-Duchenne) only the upper arm is
affected. Wrist and finger function should NOT be affected.
Immobilize the arm across the abdomen by pinning the newborn's sleeve to their shirt. - This will assist int
he healing process.
A nurse is admitting a client to the labor and delivery unit when the client states, "my water just broke",
which of the following is the priority intervention for the nurse to take? - ANS✔✔-Begin FHR Monitoring -
The greatest risk to the client and their fetus following a rupture of membranes is an umbilical cord prolapse.
FHR is the PRIORITY action.
A nurse in an antepartum clinic is providing care for a client who is at 26 weeks gestation. Upon reviewing
the clients medical record, what findings should the nurse report to the provider?
1-hr Glucose of 130 to 140 (or greater) indicates a positive test.
Hematocrit of 34% is within range - should be greater than 33%.
FHR - Should be between 110/min to 160/min for a client at 26 weeks of gestation. - ANS✔✔-Fundal height
30 cm - Fundal height should be PLUS or MINUS 2cm from weeks of gestation
A nurse is caring for a newborn who is 48 hr old.
Apgars: 7 at 1 min and 8 at 5 min of age
Birth weight: 3,515 g (7 lb 12 oz)
Maternal blood type: O+
Uncomplicated pregnancy.
Maternal use of marijuana during pregnancy
Client who gave birth plans to breastfeed.
Day 2, 0900:
Newborn awake, alert, and crying. Loosely<<<< wrapped in one blanket. Mild tremors noted. Yellow
discoloration of mucus membranes and sclera noted. Respirations 88/min, no retractions, grunting, or nasal
flaring noted. Diaper changed for small amount of urine and transitional stool.
Day 2, 0915:Blood glucose: 38 mg/dL (expected value greater than 40 to 45 gm/dL
Potential Condition? - It's NOT NAS since Mom wasn't on opiates. It's NOT Bilirubin issues so no
phototherapy. None of the babies S/S point to Respiratory distress either.
COLD STRESS
2/9
