ATI RN MATERNAL NEWBORN OB LATEST VERSION 2026-2027 EXAM
WITH ACTUAL 120 QUESTION AND CORRECT DETAILED ANSWERS
WITH RATIONALES.RATED FIVE STARS.,,, (MOST TESTED QUESTIONS)
A nurse is developing a plan of care for a newborn who is to undergo
phototherapy for hyperbilirubinemia. Which of the following actions should the
nurse include in the plan?
A) Feed the newborn 1 oz of water every 4 hours.
B) Apply lotion to the newborn's skin three times per day.
C) Remove all clothing from the newborn except the diaper.
D) Discontinue therapy if the newborn develops a rash.
Correct Answer: C) Remove all clothing from the newborn except the diaper.
Rationale
Phototherapy is used to treat hyperbilirubinemia by exposing the newborn's skin
to specific wavelengths of light that break down bilirubin. Maximum skin exposure
is essential for effective therapy, so all clothing should be removed except the
diaper to protect the genital area. Water supplements (A) are not recommended;
breastfeeding or formula feeding should continue to promote bilirubin excretion.
Lotions or ointments (B) should not be applied to the skin because they can
absorb light and cause burns. A rash (D) is not an indication to discontinue
phototherapy; it may be a transient reaction, but the nurse should monitor the
newborn's skin and notify the provider if necessary. The nurse should also ensure
the newborn's eyes are covered and monitor temperature and hydration status.
DIF: Cognitive Level: Apply (Application)
TOP: Newborn Care
MSC: NCLEX: Physiological Integrity
A nurse is caring for a client and her partner who experienced a fetal death. Which
of the following actions should the nurse take?
,A) Take photos of the newborn to give to the parents.
B) Tell the parents they can consider organ donation.
C) Encourage the parents to avoid allowing older children to visit them in the
hospital.
D) Explain to the parents the need to name the newborn.
Correct Answer: A) Take photos of the newborn to give to the parents.
Rationale
Taking photos of the newborn provides the parents with a tangible memory and
supports the grieving process after a fetal death. This is a compassionate and
therapeutic intervention that acknowledges the significance of the loss. Discussing
organ donation (B) may be appropriate but should be approached with sensitivity
and only if the parents initiate the conversation. Siblings should be allowed to visit
if the parents wish (C) to promote family grieving. Naming the newborn (D) is a
personal choice and should not be imposed on the parents. The nurse should
provide emotional support and offer resources for grief counseling.
DIF: Cognitive Level: Apply (Application)
TOP: Grief/Bereavement
MSC: NCLEX: Psychosocial Integrity
A nurse is caring for a client who is 35 weeks of gestation and is undergoing a
nonstress test that reveals a variable deceleration in the fetal heart rate. Which of
the following actions should the nurse take?
A) Give the client orange juice.
B) Elevate the client's legs.
C) Have the client change positions.
D) Establish IV access.
Correct Answer: C) Have the client change positions.
Rationale
Variable decelerations in the fetal heart rate are typically caused by umbilical cord
compression. Changing the client's position, such as moving from supine to side-
lying, can relieve cord compression and improve fetal oxygenation. Giving orange
,juice (A) may stimulate fetal movement but does not address cord compression.
Elevating the legs (B) is not the primary intervention for variable decelerations.
Establishing IV access (D) may be necessary if the decelerations persist, but
position change is the initial and most appropriate action. The nurse should also
assess the fetal heart rate tracing and notify the provider if the decelerations
continue.
DIF: Cognitive Level: Apply (Application)
TOP: Fetal Monitoring
MSC: NCLEX: Physiological Integrity
A nurse is assessing a client who gave birth vaginally 12 hours ago and palpates
her uterus to the right above the umbilicus. Which of the following interventions
should the nurse perform?
A) Reassess the client in 2 hours.
B) Administer simethicone.
C) Assist the client to empty her bladder.
D) Instruct the client to lie on her right side.
Correct Answer: C) Assist the client to empty her bladder.
Rationale
A fundus that is deviated to the right (or left) is a classic sign of a distended
bladder. A full bladder displaces the uterus, preventing adequate contraction and
increasing the risk of postpartum hemorrhage. The nurse should assist the client
to empty her bladder to allow the uterus to return to the midline and contract
effectively. Reassessing in 2 hours (A) would delay necessary intervention.
Simethicone (B) is used for gas discomfort and is not indicated. Lying on the right
side (D) would not resolve the bladder distention. The nurse should also assess
the fundus for firmness and monitor lochia.
DIF: Cognitive Level: Apply (Application)
TOP: Postpartum Assessment
MSC: NCLEX: Physiological Integrity
, A nurse is performing a routine assessment on a client who is 18 weeks of
gestation. Which of the following findings should the nurse expect?
A) Deep tendon reflexes 4+
B) Fundal height 14 cm
C) Urine protein 2+
D) Fetal heart rate 152/min
Correct Answer: D) Fetal heart rate 152/min.
Rationale
A fetal heart rate of 110 to 160 beats per minute is expected during pregnancy. A
rate of 152/min is within the normal range and is a reassuring finding. Deep
tendon reflexes 4+ (A) indicates hyperreflexia, which is not a normal finding and
may indicate preeclampsia. Fundal height at 18 weeks should be approximately 18
cm (B), not 14 cm (which would suggest intrauterine growth restriction). Urine
protein 2+ (C) is abnormal and may indicate preeclampsia or renal disease. The
nurse should continue to monitor the client's vital signs and report any abnormal
findings.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Prenatal Assessment
MSC: NCLEX: Health Promotion and Maintenance
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV
fluid replacement. Which of the following findings should the nurse report to the
provider?
A) BUN 25 mg/dL
B) Serum creatinine 0.8 mg/dL
C) Urine output of 280 mL within 8 hours
D) Urine negative for ketones
Correct Answer: A) BUN 25 mg/dL
Rationale
A BUN of 25 mg/dL is above the normal range (10-20 mg/dL) and indicates
WITH ACTUAL 120 QUESTION AND CORRECT DETAILED ANSWERS
WITH RATIONALES.RATED FIVE STARS.,,, (MOST TESTED QUESTIONS)
A nurse is developing a plan of care for a newborn who is to undergo
phototherapy for hyperbilirubinemia. Which of the following actions should the
nurse include in the plan?
A) Feed the newborn 1 oz of water every 4 hours.
B) Apply lotion to the newborn's skin three times per day.
C) Remove all clothing from the newborn except the diaper.
D) Discontinue therapy if the newborn develops a rash.
Correct Answer: C) Remove all clothing from the newborn except the diaper.
Rationale
Phototherapy is used to treat hyperbilirubinemia by exposing the newborn's skin
to specific wavelengths of light that break down bilirubin. Maximum skin exposure
is essential for effective therapy, so all clothing should be removed except the
diaper to protect the genital area. Water supplements (A) are not recommended;
breastfeeding or formula feeding should continue to promote bilirubin excretion.
Lotions or ointments (B) should not be applied to the skin because they can
absorb light and cause burns. A rash (D) is not an indication to discontinue
phototherapy; it may be a transient reaction, but the nurse should monitor the
newborn's skin and notify the provider if necessary. The nurse should also ensure
the newborn's eyes are covered and monitor temperature and hydration status.
DIF: Cognitive Level: Apply (Application)
TOP: Newborn Care
MSC: NCLEX: Physiological Integrity
A nurse is caring for a client and her partner who experienced a fetal death. Which
of the following actions should the nurse take?
,A) Take photos of the newborn to give to the parents.
B) Tell the parents they can consider organ donation.
C) Encourage the parents to avoid allowing older children to visit them in the
hospital.
D) Explain to the parents the need to name the newborn.
Correct Answer: A) Take photos of the newborn to give to the parents.
Rationale
Taking photos of the newborn provides the parents with a tangible memory and
supports the grieving process after a fetal death. This is a compassionate and
therapeutic intervention that acknowledges the significance of the loss. Discussing
organ donation (B) may be appropriate but should be approached with sensitivity
and only if the parents initiate the conversation. Siblings should be allowed to visit
if the parents wish (C) to promote family grieving. Naming the newborn (D) is a
personal choice and should not be imposed on the parents. The nurse should
provide emotional support and offer resources for grief counseling.
DIF: Cognitive Level: Apply (Application)
TOP: Grief/Bereavement
MSC: NCLEX: Psychosocial Integrity
A nurse is caring for a client who is 35 weeks of gestation and is undergoing a
nonstress test that reveals a variable deceleration in the fetal heart rate. Which of
the following actions should the nurse take?
A) Give the client orange juice.
B) Elevate the client's legs.
C) Have the client change positions.
D) Establish IV access.
Correct Answer: C) Have the client change positions.
Rationale
Variable decelerations in the fetal heart rate are typically caused by umbilical cord
compression. Changing the client's position, such as moving from supine to side-
lying, can relieve cord compression and improve fetal oxygenation. Giving orange
,juice (A) may stimulate fetal movement but does not address cord compression.
Elevating the legs (B) is not the primary intervention for variable decelerations.
Establishing IV access (D) may be necessary if the decelerations persist, but
position change is the initial and most appropriate action. The nurse should also
assess the fetal heart rate tracing and notify the provider if the decelerations
continue.
DIF: Cognitive Level: Apply (Application)
TOP: Fetal Monitoring
MSC: NCLEX: Physiological Integrity
A nurse is assessing a client who gave birth vaginally 12 hours ago and palpates
her uterus to the right above the umbilicus. Which of the following interventions
should the nurse perform?
A) Reassess the client in 2 hours.
B) Administer simethicone.
C) Assist the client to empty her bladder.
D) Instruct the client to lie on her right side.
Correct Answer: C) Assist the client to empty her bladder.
Rationale
A fundus that is deviated to the right (or left) is a classic sign of a distended
bladder. A full bladder displaces the uterus, preventing adequate contraction and
increasing the risk of postpartum hemorrhage. The nurse should assist the client
to empty her bladder to allow the uterus to return to the midline and contract
effectively. Reassessing in 2 hours (A) would delay necessary intervention.
Simethicone (B) is used for gas discomfort and is not indicated. Lying on the right
side (D) would not resolve the bladder distention. The nurse should also assess
the fundus for firmness and monitor lochia.
DIF: Cognitive Level: Apply (Application)
TOP: Postpartum Assessment
MSC: NCLEX: Physiological Integrity
, A nurse is performing a routine assessment on a client who is 18 weeks of
gestation. Which of the following findings should the nurse expect?
A) Deep tendon reflexes 4+
B) Fundal height 14 cm
C) Urine protein 2+
D) Fetal heart rate 152/min
Correct Answer: D) Fetal heart rate 152/min.
Rationale
A fetal heart rate of 110 to 160 beats per minute is expected during pregnancy. A
rate of 152/min is within the normal range and is a reassuring finding. Deep
tendon reflexes 4+ (A) indicates hyperreflexia, which is not a normal finding and
may indicate preeclampsia. Fundal height at 18 weeks should be approximately 18
cm (B), not 14 cm (which would suggest intrauterine growth restriction). Urine
protein 2+ (C) is abnormal and may indicate preeclampsia or renal disease. The
nurse should continue to monitor the client's vital signs and report any abnormal
findings.
DIF: Cognitive Level: Understand (Comprehension)
TOP: Prenatal Assessment
MSC: NCLEX: Health Promotion and Maintenance
A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV
fluid replacement. Which of the following findings should the nurse report to the
provider?
A) BUN 25 mg/dL
B) Serum creatinine 0.8 mg/dL
C) Urine output of 280 mL within 8 hours
D) Urine negative for ketones
Correct Answer: A) BUN 25 mg/dL
Rationale
A BUN of 25 mg/dL is above the normal range (10-20 mg/dL) and indicates
