Maternal Newborn Nursing ATI Exam Questions And
Answers Verified 100% Correct
A nurse in the L&D unit receives a phone call from a client who reports that her
contractions started about 2hrs ago, did not go away when she had two glasses of
water and rested, and became stronger since she started walking. Her contractions
occur every 10 min and last about 30 seconds. She hasn't had any fluid leak from
her vagina. However, she saw some blood when she wiped after voiding. Based on
this report, the nurse should recognize that the client is experiencing ---ANSWER-
True contractions
A nurse in the L&D unit is caring for a client in labor and applies an external fetal
monitor and tocotransducer. The FHR is around 140/min. Contractions are every 8
min and 30 to 40 seconds in duration. The nurse performs a vaginal exam and finds
the cervix is 2cm dilated, 50% effaced, and the fetus is at a -2 station. Which of the
following stages and phases of labor is this client experiencing? ---ANSWER-- The
first stage, latent phase
A client experiences a large gush of fluid from her vagina while walking in the
hallway of the birthing unit. The nurse's first nursing action after establishing that
the fluid is amniotic fluid should be to ---ANSWER-- Monitor the FHR for distress
A nurse in L&D is completing an admission history for a client who is at 39 weeks
of gestation. The client reports that she has been leaking fluid from her vagina for 2
days. The nurse knows that this client is at risk for ---ANSWER-- Infection
A nurse is caring for a client who is in active labor and becomes nauseous and
vomits. The client is very irritable and feels the urge to have a bowel movement.
She states "I've had enough. I can't do this anymore. I want to go home right now."
The nurse knows that these signs indicate the client is in the ---ANSWER--
Transition phase of labor
A nurse is caring for a client at 40 weeks of gestation who is experiencing
contractions every 3 to 5 min and becoming stronger. A vaginal exam reveals that
the client's cervix is 3cm dilated, 80% effaced, and -1 station. The client asks for
pain medication. Which of the following actions should the nurse take at this time?
---ANSWER-- Encourage the use of patterned breathing techniques.
,Administer opioid analgesic medication as prescribed.
Suggest application of cold.
A nurse is caring for a client who is in active labor. The client reports lower back
pain. The nurse suspects that this pain is related to a persistent occiput posterior
fetal position. Which of the following non-pharmacological nursing interventions
is appropriate? ---ANSWER-- Sacral counterpressure
A nurse is caring for a client following the administration of an epidural block and
is preparing to administer a prescribed IV fluid bolus. The client's partner asks
about the purpose of the IV fluids. Which of the following is an appropriate
response by the nurse? ---ANSWER-- "It is needed to counteract hypotension."
A nurse in the labor and delivery unit is caring for a client who is in the second
stage of labor. The client's labor has been progressing, and she is expected to
deliver vaginally in 20 min. The provider is preparing to administer lidocaine
(Xylocaine) for pain relief and perform an episiotomy. The nurse should know that
the type of regional anesthetic block that is to be administered is which of the
following? ---ANSWER-- Pudendal block
A nurse in the labor and delivery unit is caring for a client who is using patterned
breathing during labor. The client reports numbness and tingling of the fingers.
Which of the following actions should the nurse take? ---ANSWER-- Place an
oxygen mask over the client's nose and mouth.
A nurse is providing care for a client who is in active labor. Her cervix is dilated to
5cm, and her membranes are intact. Based on the use of external electronic fetal
monitoring, the nurse notes a FHR of 115 to 125/min with occasional increases up
to 150 to 155/min that last for 25 seconds, and have beat-to-beat variability of
20/min. There is no slowing of FHR from the baseline. The nurse should recognize
that this client is exhibiting signs of which of the following? ---ANSWER--
Moderate variability
FHR accelerations
Normal baseline FHR
A nurse is caring for a client who is having an induction of labor. Based on the use
of external electronic fetal monitoring, the nurse notes that the FHR variability is
decreased and resembles a straight line. The client has not received pain
,medication. Which of the following should occur first before the nurse can apply
an internal scalp electrode? ---ANSWER-- Rupture of the membranes
A nurse is reviewing the electronic monitor tracing of a client who is in active
labor. The nurse knows that a fetus receives more oxygen when which of the
following appears on the tracing? ---ANSWER-- Relaxation between uterine
contractions
A nurse is caring for a client who is in labor and observes late decelerations on the
electronic fetal monitor. Which of the following is the first action the nurse should
take? ---ANSWER-- Assist the client into the left-lateral position
A nurse is performing Leopold maneuvers on a client who is in labor. Which of the
following techniques should the nurse use to identify the fetal lie? ---ANSWER--
Palpate the fundus of the uterus.
A nurse is caring for a client and her partner during the second stage of labor. The
client's partner asks the nurse to explain how he will know when crowning occurs.
Which of the following is an appropriate response by the nurse? ---ANSWER--
"The vaginal area will bulge as the baby's head appears."
A nurse is caring for a client in the third stage of labor. Which of the following
findings indicate that placental separation has occurred? ---ANSWER--
Lengthening of the umbilical cord.
Appearance of dark blood from the vagina.
Fundus is firm upon palpation.
A nurse is caring for a client who is in the transition phase of labor and reports that
she needs to have a bowel movement with the peak of contractions. Which of the
following is an appropriate nursing intervention? ---ANSWER-- Prepare for an
impending delivery.
A nurse in labor and delivery is planning care for a newly admitted client who
reports she is in labor and has been having vaginal bleeding for 2 weeks. Which of
the following should the nurse include in the plan of care? ---ANSWER-- Defer
vaginal examinations
A nurse is caring for a client who is in the first stage of labor and encourages the
, client to void every 2 hr. The nurse explains that a ---ANSWER-- Distended
bladder reduces pelvic space needed for birth.
A nurse is performing a fundal assessment for a client in her second postpartum
day and observes the client's perineal pad for lochia. She notes the pad to be
saturated approximately 12 cm with lochia that is bright red in color and contains
small clots. The nurse knows that this finding is ---ANSWER-- Moderate lochia
rubra
During ambulation to the bathroom, a postpartum client experiences a gush of dark
red blood that soon stops. On assessment, a nurse finds the client's uterus to be firm
and midline and at the level of the umbilicus. The nurse interprets this finding as --
-ANSWER-- A normal postural discharge of lochia
A nurse is assessing postpartum client for fundal height, location, and consistency.
The fundus is found to be displaced laterally to the right, and there is uterine atony.
Which of the following is the cause of the uterine atony? ---ANSWER-- Urinary
retention
A nurse is completing postpartum discharge teaching to a client who had no
immunity to varicella and was given varicella vaccine. Which of the following
statements by the client indicates understanding of the teaching? ---ANSWER-- "I
need a second vaccination at my postpartum visit."
A nurse is caring for a client who is 1 hr following a vaginal birth and experiencing
uncontrollable shaking. The nurse should understand that the shaking is due to
which of the following? ---ANSWER-- A change in body fluids
The metabolic effort of labor
A nurse concludes that the father of an infant is not showing positive signs of
parent-infant bonding and appears to be very anxious and nervous when the
infant's mother asks him to bring her the infant. Which of the following is an
appropriate nursing intervention to promote father-infant bonding? ---ANSWER--
Provide education about infant care when the father is present
A client in the early postpartum period is very excited and talkative. She is
repeatedly telling the nurse every detail of her labor and birth. Because the client
Answers Verified 100% Correct
A nurse in the L&D unit receives a phone call from a client who reports that her
contractions started about 2hrs ago, did not go away when she had two glasses of
water and rested, and became stronger since she started walking. Her contractions
occur every 10 min and last about 30 seconds. She hasn't had any fluid leak from
her vagina. However, she saw some blood when she wiped after voiding. Based on
this report, the nurse should recognize that the client is experiencing ---ANSWER-
True contractions
A nurse in the L&D unit is caring for a client in labor and applies an external fetal
monitor and tocotransducer. The FHR is around 140/min. Contractions are every 8
min and 30 to 40 seconds in duration. The nurse performs a vaginal exam and finds
the cervix is 2cm dilated, 50% effaced, and the fetus is at a -2 station. Which of the
following stages and phases of labor is this client experiencing? ---ANSWER-- The
first stage, latent phase
A client experiences a large gush of fluid from her vagina while walking in the
hallway of the birthing unit. The nurse's first nursing action after establishing that
the fluid is amniotic fluid should be to ---ANSWER-- Monitor the FHR for distress
A nurse in L&D is completing an admission history for a client who is at 39 weeks
of gestation. The client reports that she has been leaking fluid from her vagina for 2
days. The nurse knows that this client is at risk for ---ANSWER-- Infection
A nurse is caring for a client who is in active labor and becomes nauseous and
vomits. The client is very irritable and feels the urge to have a bowel movement.
She states "I've had enough. I can't do this anymore. I want to go home right now."
The nurse knows that these signs indicate the client is in the ---ANSWER--
Transition phase of labor
A nurse is caring for a client at 40 weeks of gestation who is experiencing
contractions every 3 to 5 min and becoming stronger. A vaginal exam reveals that
the client's cervix is 3cm dilated, 80% effaced, and -1 station. The client asks for
pain medication. Which of the following actions should the nurse take at this time?
---ANSWER-- Encourage the use of patterned breathing techniques.
,Administer opioid analgesic medication as prescribed.
Suggest application of cold.
A nurse is caring for a client who is in active labor. The client reports lower back
pain. The nurse suspects that this pain is related to a persistent occiput posterior
fetal position. Which of the following non-pharmacological nursing interventions
is appropriate? ---ANSWER-- Sacral counterpressure
A nurse is caring for a client following the administration of an epidural block and
is preparing to administer a prescribed IV fluid bolus. The client's partner asks
about the purpose of the IV fluids. Which of the following is an appropriate
response by the nurse? ---ANSWER-- "It is needed to counteract hypotension."
A nurse in the labor and delivery unit is caring for a client who is in the second
stage of labor. The client's labor has been progressing, and she is expected to
deliver vaginally in 20 min. The provider is preparing to administer lidocaine
(Xylocaine) for pain relief and perform an episiotomy. The nurse should know that
the type of regional anesthetic block that is to be administered is which of the
following? ---ANSWER-- Pudendal block
A nurse in the labor and delivery unit is caring for a client who is using patterned
breathing during labor. The client reports numbness and tingling of the fingers.
Which of the following actions should the nurse take? ---ANSWER-- Place an
oxygen mask over the client's nose and mouth.
A nurse is providing care for a client who is in active labor. Her cervix is dilated to
5cm, and her membranes are intact. Based on the use of external electronic fetal
monitoring, the nurse notes a FHR of 115 to 125/min with occasional increases up
to 150 to 155/min that last for 25 seconds, and have beat-to-beat variability of
20/min. There is no slowing of FHR from the baseline. The nurse should recognize
that this client is exhibiting signs of which of the following? ---ANSWER--
Moderate variability
FHR accelerations
Normal baseline FHR
A nurse is caring for a client who is having an induction of labor. Based on the use
of external electronic fetal monitoring, the nurse notes that the FHR variability is
decreased and resembles a straight line. The client has not received pain
,medication. Which of the following should occur first before the nurse can apply
an internal scalp electrode? ---ANSWER-- Rupture of the membranes
A nurse is reviewing the electronic monitor tracing of a client who is in active
labor. The nurse knows that a fetus receives more oxygen when which of the
following appears on the tracing? ---ANSWER-- Relaxation between uterine
contractions
A nurse is caring for a client who is in labor and observes late decelerations on the
electronic fetal monitor. Which of the following is the first action the nurse should
take? ---ANSWER-- Assist the client into the left-lateral position
A nurse is performing Leopold maneuvers on a client who is in labor. Which of the
following techniques should the nurse use to identify the fetal lie? ---ANSWER--
Palpate the fundus of the uterus.
A nurse is caring for a client and her partner during the second stage of labor. The
client's partner asks the nurse to explain how he will know when crowning occurs.
Which of the following is an appropriate response by the nurse? ---ANSWER--
"The vaginal area will bulge as the baby's head appears."
A nurse is caring for a client in the third stage of labor. Which of the following
findings indicate that placental separation has occurred? ---ANSWER--
Lengthening of the umbilical cord.
Appearance of dark blood from the vagina.
Fundus is firm upon palpation.
A nurse is caring for a client who is in the transition phase of labor and reports that
she needs to have a bowel movement with the peak of contractions. Which of the
following is an appropriate nursing intervention? ---ANSWER-- Prepare for an
impending delivery.
A nurse in labor and delivery is planning care for a newly admitted client who
reports she is in labor and has been having vaginal bleeding for 2 weeks. Which of
the following should the nurse include in the plan of care? ---ANSWER-- Defer
vaginal examinations
A nurse is caring for a client who is in the first stage of labor and encourages the
, client to void every 2 hr. The nurse explains that a ---ANSWER-- Distended
bladder reduces pelvic space needed for birth.
A nurse is performing a fundal assessment for a client in her second postpartum
day and observes the client's perineal pad for lochia. She notes the pad to be
saturated approximately 12 cm with lochia that is bright red in color and contains
small clots. The nurse knows that this finding is ---ANSWER-- Moderate lochia
rubra
During ambulation to the bathroom, a postpartum client experiences a gush of dark
red blood that soon stops. On assessment, a nurse finds the client's uterus to be firm
and midline and at the level of the umbilicus. The nurse interprets this finding as --
-ANSWER-- A normal postural discharge of lochia
A nurse is assessing postpartum client for fundal height, location, and consistency.
The fundus is found to be displaced laterally to the right, and there is uterine atony.
Which of the following is the cause of the uterine atony? ---ANSWER-- Urinary
retention
A nurse is completing postpartum discharge teaching to a client who had no
immunity to varicella and was given varicella vaccine. Which of the following
statements by the client indicates understanding of the teaching? ---ANSWER-- "I
need a second vaccination at my postpartum visit."
A nurse is caring for a client who is 1 hr following a vaginal birth and experiencing
uncontrollable shaking. The nurse should understand that the shaking is due to
which of the following? ---ANSWER-- A change in body fluids
The metabolic effort of labor
A nurse concludes that the father of an infant is not showing positive signs of
parent-infant bonding and appears to be very anxious and nervous when the
infant's mother asks him to bring her the infant. Which of the following is an
appropriate nursing intervention to promote father-infant bonding? ---ANSWER--
Provide education about infant care when the father is present
A client in the early postpartum period is very excited and talkative. She is
repeatedly telling the nurse every detail of her labor and birth. Because the client
