2024 ATI Maternal Newborn 2019 Exam
Updated 2024 with All Questions, Answers
and Rationale
Question 1:
A nurse is assessing a client who is at 32 weeks of gestation and is receiving
magnesium sulphate via continuous IV infusion. Which of the following
findings should the nurse report to the provider?
A. Decrease in frequency of contractions
B. BP 150/100 mm Hg
C. Absent deep tendon reflexes
D. Urinary output 35 mL/hr
Show correct answer and explanation
Explanation
Absent deep tendon reflexes are a sign of magnesium toxicity, which can occur
with high levels of magnesium in the bloodstream. This can be a serious
complication that requires immediate atention from the provider.
Option A, a decrease in frequency of contractions, is actually a desired effect of
magnesium sulfate in the management of preterm labor. It is not a cause for
concern.
Option B, a blood pressure reading of 150/100 mm Hg, is high, but it is not
necessarily related to the administration of magnesium sulfate. However, it
should still be reported to the provider for appropriate management.
Option D, a urinary output of 35 mL/hr, is below the normal range but it may still
be within an acceptable range for a client receiving magnesium sulfate. The
provider should be notified if urinary output continues to decrease or if it falls
,below a certain threshold.
Question 2:
A nurse is teaching a client and her partner about the technique of
counterpressure during labor. Which of the following statements by the nurse
is appropriate?
A. “Your partner will apply pressure to the top of your uterus during contractions.”
B. “Your partner will apply steady pressure with a tennis ball to your lower
back.”
C. “Your partner will apply continuous, firm pressure between your thumb and
index finger.”
D. “Your partner will apply upward pressure on your lower abdomen between
contractions.”
Show correct answer and explanation
Explanation
Counterpressure is a technique that involves applying pressure to specific areas
of the body during labor to help alleviate pain and discomfort. This technique is
particularly helpful during the active phase of labor when contractions are strong
and painful. The most common area to apply counterpressure is the lower back,
as this is where many women experience the most intense pain during labor.
Option A “Your partner will apply pressure to the top of your uterus during
contractions” is incorrect as applying pressure to the top of the uterus is not a
recommended technique and could be harmful to the mother and the baby.
, Option C “Your partner will apply continuous, firm pressure between your thumb
and index finger” is incorrect as this technique is used to alleviate pain and
discomfort during contractions in the hand and wrist, not for counterpressure.
Option D “Your partner will apply upward pressure on your lower abdomen
between contractions” is incorrect as this technique is used to help turn a baby
who is in a posterior position, not for counterpressure.
Question 3:
A nurse is caring for a client who is at 30 weeks of gestation and receiving
magnesium sulfate for preeclampsia. The nurse should recognize which of the
following manifestations as an adverse reaction to the medication?
A. Hypertension
B. Hypoglycemia
C. Respiratory rate 16/min
D. Urine output 20 mL/hr
Show correct answer and explanation
Explanation
Magnesium sulfate is a medication used to prevent seizures in clients with
preeclampsia. However, it can cause adverse reactions, including respiratory
depression, which can lead to a decrease in the respiratory rate. The normal
Updated 2024 with All Questions, Answers
and Rationale
Question 1:
A nurse is assessing a client who is at 32 weeks of gestation and is receiving
magnesium sulphate via continuous IV infusion. Which of the following
findings should the nurse report to the provider?
A. Decrease in frequency of contractions
B. BP 150/100 mm Hg
C. Absent deep tendon reflexes
D. Urinary output 35 mL/hr
Show correct answer and explanation
Explanation
Absent deep tendon reflexes are a sign of magnesium toxicity, which can occur
with high levels of magnesium in the bloodstream. This can be a serious
complication that requires immediate atention from the provider.
Option A, a decrease in frequency of contractions, is actually a desired effect of
magnesium sulfate in the management of preterm labor. It is not a cause for
concern.
Option B, a blood pressure reading of 150/100 mm Hg, is high, but it is not
necessarily related to the administration of magnesium sulfate. However, it
should still be reported to the provider for appropriate management.
Option D, a urinary output of 35 mL/hr, is below the normal range but it may still
be within an acceptable range for a client receiving magnesium sulfate. The
provider should be notified if urinary output continues to decrease or if it falls
,below a certain threshold.
Question 2:
A nurse is teaching a client and her partner about the technique of
counterpressure during labor. Which of the following statements by the nurse
is appropriate?
A. “Your partner will apply pressure to the top of your uterus during contractions.”
B. “Your partner will apply steady pressure with a tennis ball to your lower
back.”
C. “Your partner will apply continuous, firm pressure between your thumb and
index finger.”
D. “Your partner will apply upward pressure on your lower abdomen between
contractions.”
Show correct answer and explanation
Explanation
Counterpressure is a technique that involves applying pressure to specific areas
of the body during labor to help alleviate pain and discomfort. This technique is
particularly helpful during the active phase of labor when contractions are strong
and painful. The most common area to apply counterpressure is the lower back,
as this is where many women experience the most intense pain during labor.
Option A “Your partner will apply pressure to the top of your uterus during
contractions” is incorrect as applying pressure to the top of the uterus is not a
recommended technique and could be harmful to the mother and the baby.
, Option C “Your partner will apply continuous, firm pressure between your thumb
and index finger” is incorrect as this technique is used to alleviate pain and
discomfort during contractions in the hand and wrist, not for counterpressure.
Option D “Your partner will apply upward pressure on your lower abdomen
between contractions” is incorrect as this technique is used to help turn a baby
who is in a posterior position, not for counterpressure.
Question 3:
A nurse is caring for a client who is at 30 weeks of gestation and receiving
magnesium sulfate for preeclampsia. The nurse should recognize which of the
following manifestations as an adverse reaction to the medication?
A. Hypertension
B. Hypoglycemia
C. Respiratory rate 16/min
D. Urine output 20 mL/hr
Show correct answer and explanation
Explanation
Magnesium sulfate is a medication used to prevent seizures in clients with
preeclampsia. However, it can cause adverse reactions, including respiratory
depression, which can lead to a decrease in the respiratory rate. The normal
