2025 RN Maternal Newborn ATI Proctored Exam
Study Guide | 70 Practice Questions with NGN
Case Scenarios & Rationales
A nurse is planning care for a client who is 2 hr postpartum. Which of the following
interventions should the nurse plan to implement during the taking-hold phase of
postpartum behavioral adjustment? - - correct ans- -A. Discuss contraceptive options
with the client and her partner.
B. Repeat information to ensure client understanding.
C. Listen to the client and her partner as they reflect upon the birth experience.
D. Demonstrate to the client how to perform a newborn bath.
Answer: Demonstrate to the client how to perform a newborn bath.
A. Discuss contraceptive options with the client and her partner.
The discussing of contraceptive options occurs during the letting-go phase. This phase
focuses on moving forward as a family with interchanging members.
B. Repeat information to ensure client understanding.
The repeating of information to ensure client understanding occurs during the taking-in
phase. During this phase, which is experienced on the first postpartum day, the client
displays dependent and passive behaviors. Due to excitement and fatigue, the client is
unable to retain information. Therefore, the nurse should repeat instructions to ensure
that the client understands what is being said.
C. Listen to the client and her partner as they reflect upon the birth experience.
Listening to the client and her partner reflect upon the birth experience occurs during
the taking-in phase. During this phase, the new mother is focused on herself and
meeting her basic needs. There is also much excitement about the newborn and the
birth experience. Therefore, the nurse should allow the client to reflect, ensuring a
healthy transition and a successful adaptation into the new family unit.
,D. Demonstrate to the client how to perform a newborn bath.
Demonstrating to the client how to perform a newborn bath occurs during the taking-
hold phase. The new parent moves from being passively dependent to taking a stronger
interest in her new role as a mother. She is now focusing on the care her newborn and
acquiring parenting skills. The nurse sh
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal
visit. Which of the following findings should the nurse report to the provider? - - correct
ans- -A. Swelling of the face
B. Varicose veins in the calves
C. Nonpitting 1+ ankle edema
D. Hyperpigmentation of the cheeks
Answer: Swelling of the face
A. Swelling of the face
Swelling of the face, sacral area, and fingers can indicate gestational hypertension or
preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid
moves out of the intravascular compartment into the tissues, causing edema.
B. Varicose veins in the calves
Varicose veins are an expected finding in the second trimester. The increase in
hormones during pregnancy causes the relaxation of the smooth muscle of the vascular
system, leading to vessel dilation and vasocongestion. Additionally, the weight of the
enlarging uterus on the pelvic veins decreases the return of blood from the lower
extremities.
C. Nonpitting 1+ ankle edema
Nonpitting edema of the lower extremities is an expected finding in the third trimester.
Warm weather, sitting or standing for prolonged periods of time, and tight clothing can
increase edema.
, D. Hyperpigmentation of the cheeks
Hyperpigmentation of the cheeks, areola, vulva, and linea nigra are expected findings in
the second trimester. The anterior pituitary increases the production of melanocyte-
stimulating hormone, which leads to hyperpigmentation of the skin.
A nuse is assessing a newborn for manifestations of hypoglycemia. Which of the
following findings should the nurse expect? - - correct ans- -A. Jitteriness
B. Hypertonia
C. Abdominal distention
D. Mottling
Answer: Jitteriness
A. Jitteriness
Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability,
apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia.
Newborns who are small or large for gestational age and late preterm newborns are at
an increased risk for hypoglycemia.
B. Hypertonia
Hypotonia, rather than hypertonia, is a manifestation of hypoglycemia. Hypertonia is a
manifestation of opioid withdrawal.
C. Abdominal distention
Abdominal distention is not a manifestation of hypoglycemia. Abdominal distention is a
finding in newborns who have hypocalcemia.
D. Mottling
Mottling is not a manifestation of hypoglycemia. It can be a normal variation seen in
newborns. Also, it is a manifestation of opioid withdrawal.
Study Guide | 70 Practice Questions with NGN
Case Scenarios & Rationales
A nurse is planning care for a client who is 2 hr postpartum. Which of the following
interventions should the nurse plan to implement during the taking-hold phase of
postpartum behavioral adjustment? - - correct ans- -A. Discuss contraceptive options
with the client and her partner.
B. Repeat information to ensure client understanding.
C. Listen to the client and her partner as they reflect upon the birth experience.
D. Demonstrate to the client how to perform a newborn bath.
Answer: Demonstrate to the client how to perform a newborn bath.
A. Discuss contraceptive options with the client and her partner.
The discussing of contraceptive options occurs during the letting-go phase. This phase
focuses on moving forward as a family with interchanging members.
B. Repeat information to ensure client understanding.
The repeating of information to ensure client understanding occurs during the taking-in
phase. During this phase, which is experienced on the first postpartum day, the client
displays dependent and passive behaviors. Due to excitement and fatigue, the client is
unable to retain information. Therefore, the nurse should repeat instructions to ensure
that the client understands what is being said.
C. Listen to the client and her partner as they reflect upon the birth experience.
Listening to the client and her partner reflect upon the birth experience occurs during
the taking-in phase. During this phase, the new mother is focused on herself and
meeting her basic needs. There is also much excitement about the newborn and the
birth experience. Therefore, the nurse should allow the client to reflect, ensuring a
healthy transition and a successful adaptation into the new family unit.
,D. Demonstrate to the client how to perform a newborn bath.
Demonstrating to the client how to perform a newborn bath occurs during the taking-
hold phase. The new parent moves from being passively dependent to taking a stronger
interest in her new role as a mother. She is now focusing on the care her newborn and
acquiring parenting skills. The nurse sh
A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal
visit. Which of the following findings should the nurse report to the provider? - - correct
ans- -A. Swelling of the face
B. Varicose veins in the calves
C. Nonpitting 1+ ankle edema
D. Hyperpigmentation of the cheeks
Answer: Swelling of the face
A. Swelling of the face
Swelling of the face, sacral area, and fingers can indicate gestational hypertension or
preeclampsia. Reduction in renal perfusion leads to sodium and water retention. Fluid
moves out of the intravascular compartment into the tissues, causing edema.
B. Varicose veins in the calves
Varicose veins are an expected finding in the second trimester. The increase in
hormones during pregnancy causes the relaxation of the smooth muscle of the vascular
system, leading to vessel dilation and vasocongestion. Additionally, the weight of the
enlarging uterus on the pelvic veins decreases the return of blood from the lower
extremities.
C. Nonpitting 1+ ankle edema
Nonpitting edema of the lower extremities is an expected finding in the third trimester.
Warm weather, sitting or standing for prolonged periods of time, and tight clothing can
increase edema.
, D. Hyperpigmentation of the cheeks
Hyperpigmentation of the cheeks, areola, vulva, and linea nigra are expected findings in
the second trimester. The anterior pituitary increases the production of melanocyte-
stimulating hormone, which leads to hyperpigmentation of the skin.
A nuse is assessing a newborn for manifestations of hypoglycemia. Which of the
following findings should the nurse expect? - - correct ans- -A. Jitteriness
B. Hypertonia
C. Abdominal distention
D. Mottling
Answer: Jitteriness
A. Jitteriness
Jitteriness, tachypnea, retractions, nasal flaring, lethargy, temperature instability,
apnea, abnormal cry, poor feeding, and seizures are expected findings of hypoglycemia.
Newborns who are small or large for gestational age and late preterm newborns are at
an increased risk for hypoglycemia.
B. Hypertonia
Hypotonia, rather than hypertonia, is a manifestation of hypoglycemia. Hypertonia is a
manifestation of opioid withdrawal.
C. Abdominal distention
Abdominal distention is not a manifestation of hypoglycemia. Abdominal distention is a
finding in newborns who have hypocalcemia.
D. Mottling
Mottling is not a manifestation of hypoglycemia. It can be a normal variation seen in
newborns. Also, it is a manifestation of opioid withdrawal.
