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ATI RN MATERNAL-NEWBORN 2023 ACTUAL
QUESTIONS ANSWERS AND RATIONALES
JUST RELEASED
1. A nurse is assessing a client at 36 weeks gestation. The client
reports sudden gush of fluid from the vagina. What is the priority
action?
A. Check fetal heart rate
B. Assess maternal vital signs
C. Notify the provider
D. Collect a urine sample
Answer: A
Rationale: A sudden gush may indicate rupture of membranes. Fetal
status must be assessed immediately.
2. NGN: A laboring client at 4 cm presents with late decelerations on
the fetal monitor. Which interventions should the nurse implement?
(Select all that apply)
A. Administer oxygen 10 L/min via nonrebreather
B. Reposition client to left lateral
C. Increase oxytocin infusion
D. Notify provider
E. Encourage pushing
Answer: B, D
Rationale: Late decels indicate uteroplacental insufficiency.
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Repositioning improves placental perfusion; notify provider. Oxygen
may be used, but 10 L/min is not first-line unless ordered. Increasing
oxytocin worsens late decels. Pushing is inappropriate.
3. A client at 28 weeks gestation is diagnosed with preeclampsia.
Which finding requires immediate intervention?
A. Mild headache
B. BP 180/110 mmHg
C. 2+ proteinuria
D. Slight edema
Answer: B
Rationale: Severe hypertension (>160/110) is an emergency and
requires immediate action to prevent complications.
4. NGN: A postpartum client 12 hours after vaginal birth reports heavy
vaginal bleeding and a soft, boggy uterus. What should the nurse do?
(Select all that apply)
A. Massage the uterus
B. Monitor vital signs
C. Increase IV fluids
D. Encourage ambulation
E. Notify the provider
Answer: A, B, C, E
Rationale: Boggy uterus with heavy bleeding indicates postpartum
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hemorrhage. Massage the fundus, monitor vitals, administer fluids, and
notify provider. Ambulation is inappropriate.
5. A newborn is 1 hour old. Which assessment requires immediate
intervention?
A. Heart rate 140 bpm
B. Respiratory rate 70/min with nasal flaring
C. Acrocyanosis of hands and feet
D. Moro reflex present
Answer: B
Rationale: Tachypnea with nasal flaring indicates respiratory distress
and needs immediate attention.
6. NGN: A laboring client’s fetal monitor shows variable decelerations.
What should the nurse do? (Select all that apply)
A. Reposition client
B. Perform vaginal exam for prolapsed cord
C. Apply oxygen via face mask
D. Increase oxytocin
E. Notify provider
Answer: A, B, C, E
Rationale: Variable decels indicate cord compression. Repositioning and
checking for prolapse improve fetal oxygenation. Notify provider.
Oxygen may help. Oxytocin should not be increased.
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7. A client at 32 weeks gestation is prescribed betamethasone. The
nurse should monitor for:
A. Hypoglycemia
B. Hyperglycemia
C. Bradycardia
D. Hypertension
Answer: B
Rationale: Betamethasone can increase blood glucose levels, especially
in clients with diabetes.
8. NGN: A postpartum client is 24 hours after cesarean birth. She
reports incisional pain, redness, and fever 38.5°C. What actions should
the nurse take? (Select all that apply)
A. Assess incision for drainage
B. Encourage ambulation
C. Administer prescribed analgesics
D. Notify provider
E. Apply ice packs
Answer: A, C, D
Rationale: Signs of infection require assessment, pain management,
and provider notification. Ambulation is appropriate but not priority. Ice
packs are not indicated for infection.
9. A client is at 20 weeks gestation. Which finding is abnormal and
requires follow-up?
ATI RN MATERNAL-NEWBORN 2023 ACTUAL
QUESTIONS ANSWERS AND RATIONALES
JUST RELEASED
1. A nurse is assessing a client at 36 weeks gestation. The client
reports sudden gush of fluid from the vagina. What is the priority
action?
A. Check fetal heart rate
B. Assess maternal vital signs
C. Notify the provider
D. Collect a urine sample
Answer: A
Rationale: A sudden gush may indicate rupture of membranes. Fetal
status must be assessed immediately.
2. NGN: A laboring client at 4 cm presents with late decelerations on
the fetal monitor. Which interventions should the nurse implement?
(Select all that apply)
A. Administer oxygen 10 L/min via nonrebreather
B. Reposition client to left lateral
C. Increase oxytocin infusion
D. Notify provider
E. Encourage pushing
Answer: B, D
Rationale: Late decels indicate uteroplacental insufficiency.
,2
Repositioning improves placental perfusion; notify provider. Oxygen
may be used, but 10 L/min is not first-line unless ordered. Increasing
oxytocin worsens late decels. Pushing is inappropriate.
3. A client at 28 weeks gestation is diagnosed with preeclampsia.
Which finding requires immediate intervention?
A. Mild headache
B. BP 180/110 mmHg
C. 2+ proteinuria
D. Slight edema
Answer: B
Rationale: Severe hypertension (>160/110) is an emergency and
requires immediate action to prevent complications.
4. NGN: A postpartum client 12 hours after vaginal birth reports heavy
vaginal bleeding and a soft, boggy uterus. What should the nurse do?
(Select all that apply)
A. Massage the uterus
B. Monitor vital signs
C. Increase IV fluids
D. Encourage ambulation
E. Notify the provider
Answer: A, B, C, E
Rationale: Boggy uterus with heavy bleeding indicates postpartum
,3
hemorrhage. Massage the fundus, monitor vitals, administer fluids, and
notify provider. Ambulation is inappropriate.
5. A newborn is 1 hour old. Which assessment requires immediate
intervention?
A. Heart rate 140 bpm
B. Respiratory rate 70/min with nasal flaring
C. Acrocyanosis of hands and feet
D. Moro reflex present
Answer: B
Rationale: Tachypnea with nasal flaring indicates respiratory distress
and needs immediate attention.
6. NGN: A laboring client’s fetal monitor shows variable decelerations.
What should the nurse do? (Select all that apply)
A. Reposition client
B. Perform vaginal exam for prolapsed cord
C. Apply oxygen via face mask
D. Increase oxytocin
E. Notify provider
Answer: A, B, C, E
Rationale: Variable decels indicate cord compression. Repositioning and
checking for prolapse improve fetal oxygenation. Notify provider.
Oxygen may help. Oxytocin should not be increased.
, 4
7. A client at 32 weeks gestation is prescribed betamethasone. The
nurse should monitor for:
A. Hypoglycemia
B. Hyperglycemia
C. Bradycardia
D. Hypertension
Answer: B
Rationale: Betamethasone can increase blood glucose levels, especially
in clients with diabetes.
8. NGN: A postpartum client is 24 hours after cesarean birth. She
reports incisional pain, redness, and fever 38.5°C. What actions should
the nurse take? (Select all that apply)
A. Assess incision for drainage
B. Encourage ambulation
C. Administer prescribed analgesics
D. Notify provider
E. Apply ice packs
Answer: A, C, D
Rationale: Signs of infection require assessment, pain management,
and provider notification. Ambulation is appropriate but not priority. Ice
packs are not indicated for infection.
9. A client is at 20 weeks gestation. Which finding is abnormal and
requires follow-up?
