1 | Page
ATI RN Maternal Newborn A Questions and
Correct Answers
Exhibit 1: Medical hx
Newborn delivered by repeat cesarean birth at 40 weeks of
gestation. Birth weight 3,515 g (7 lb 12 oz) Apgar scores 8 at 1 min
and 9 at 5 min. Maternal history of methadone use during
pregnancy.
Exhibit 2: VS
@0700: Heart rate 156/min. Respiratory rate 58/min. Temperature
37.2° C (98.9° F) Oxygen saturation 98% on room air
@1100: Heart rate 160/min. Respiratory rate 60/min. Temperature
37.3° C (99.2° F) Oxygen saturation 96% on room air
Exhibit 3: Phys Exam
Newborn is inconsolable with a high-pitched cry. Newborn sucks
vigorously on pacifier but breastfeeds poorly. Respirations
unlabored. Lungs sound clear on auscultation. Increased muscle
tone with moderate to severe tremors when disturbed. Hyperactive
Moro reflex noted. Several loose stools today.
Exhibit 4: Diagnostic Results
Maternal urine toxicology screen positive for opiates (-). Newborn
urine toxicology screen positive for opiates (- Ans: — Respiratory
findings is incorrect. The newborn's respiratory rate is within the
expected reference range of 30 to 60/min. There is no indication
the newborn has an alteration in respiratory status; therefore, this
finding does not need to be reported to the provider.
Temperature is incorrect. The newborn's temperature is within the
expected reference range of 36.5° to 37.5° C (97.7° to 99.5° F).
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Therefore, this finding does not need to be reported to the
provider.
Oxygen saturation is incorrect. The newborn's oxygen saturation is
within the expected reference range of greater than 94%; therefore,
this finding does not need to be reported to the provider.
Central nervous system findings is correct. The newborn is
displaying inconsolability, high-pitched cry, increased muscle tone,
tremors, hyperactive Moro reflex, and excessive sucking. These
findings are manifestations of NAS and should be reported to the
provider.
Gastrointestinal findings is correct. The newborn is displaying
poor feeding and loose stools. These findings are manifestations
of NAS and should be reported to the provider.
Exhibit 1: RN note
@ 0900: Client reports a small amount of bright red blood in their
underwear upon awakening. Client denies contractions or
abdominal pain. External fetal monitor applied.
@0930: Client passed large amount of bright red blood from
vagina. Denies pain. Uterine tone soft and nontender to palpation.
Contraction pattern: no contractions noted. Fetal heart rate
pattern: Fetal heart rate baseline 135/min. Moderate variability. No
decelerations noted.
Exhibit 2: VS
@0900: Temperature 36.2°C (97.2° F)Pulse rate 78/min. Respiratory
rate 20/min. Blood pressure 112/64 mmHg. Fetal heart rate
132/min
@0930: Pulse rate 82/min. Blood pressure 116/60 mmHg. Fetal
heart rate 160/min
Exhibit 3: Medical hx
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G4P3. 30 weeks gestation. Previous pregnancies delivered via
cesarean section Ans: — When generating solutions, inserting a
large bore intravenous catheter is indicated. Clients who have third
trimester vaginal bleeding may experience a sudden hemorrhage
and require fluid resuscitation or the administration of blood
products. The nurse should weigh perineal pads. Weighing
perineal pads after use will provide a more accurate assessment of
the volume of blood loss that the client is experiencing.
When generating solutions, the nurse should not administer
methotrexate or assess for cervical dilation because it is
contraindicated for this client. Methotrexate is an antimetabolite
and folic acid antagonist which destroys rapidly dividing cells. It
can be administered during pregnancy to medically resolve an
ectopic pregnancy during the first trimester. Assessing cervical
dilation is contraindicated for any pregnant client who is
experiencing vaginal bleeding. Manipulation of the cervix during
the examination may result in further damage to the placenta and
compromise the well-being of the client and fetus.
A nurse is assessing the newborn of a client who took selective
serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the
following manifestations should the nurse identify as an indication
of withdrawal from an SSRI?
a. Large for gestational age
b. Hyperglycemia
c. Bradypnea
d. Vomiting Ans: — d. Vomiting
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Expected manifestations associated with fetal exposure to SSRIs
include irritability, agitation, tremors, diarrhea, and vomiting.
These manifestations typically last 2 days.
A nurse in a family planning clinic is caring for a client who
requests an oral contraceptive. Which of the following findings in
the client's history should the nurse recognize as a
contraindication to oral contraceptives? (Select all that apply)
a. Cholecystitis
b. Hypertension
c. Human papillomavirus
d. Migraine headaches
e. Anxiety disorder Ans: — Cholecystitis, hypertension, and
migraine headaches is correct. A history of gallbladder disease is a
contraindication for the use of oral contraceptives. Hypertension is
a contraindication for the use of oral contraceptives. A history of
migraine headaches is a contraindication for the use of oral
contraceptives.
HPV and anxiety disorder is incorrect. The presence of human
papillomavirus is not a contraindication for the use of oral
contraceptives. The presence of an anxiety disorder is not a
contraindication for the use of oral contraceptives.
A nurse is caring for a newborn.
Exhibit 1: Medical hx
© 2025 All rights reserved
ATI RN Maternal Newborn A Questions and
Correct Answers
Exhibit 1: Medical hx
Newborn delivered by repeat cesarean birth at 40 weeks of
gestation. Birth weight 3,515 g (7 lb 12 oz) Apgar scores 8 at 1 min
and 9 at 5 min. Maternal history of methadone use during
pregnancy.
Exhibit 2: VS
@0700: Heart rate 156/min. Respiratory rate 58/min. Temperature
37.2° C (98.9° F) Oxygen saturation 98% on room air
@1100: Heart rate 160/min. Respiratory rate 60/min. Temperature
37.3° C (99.2° F) Oxygen saturation 96% on room air
Exhibit 3: Phys Exam
Newborn is inconsolable with a high-pitched cry. Newborn sucks
vigorously on pacifier but breastfeeds poorly. Respirations
unlabored. Lungs sound clear on auscultation. Increased muscle
tone with moderate to severe tremors when disturbed. Hyperactive
Moro reflex noted. Several loose stools today.
Exhibit 4: Diagnostic Results
Maternal urine toxicology screen positive for opiates (-). Newborn
urine toxicology screen positive for opiates (- Ans: — Respiratory
findings is incorrect. The newborn's respiratory rate is within the
expected reference range of 30 to 60/min. There is no indication
the newborn has an alteration in respiratory status; therefore, this
finding does not need to be reported to the provider.
Temperature is incorrect. The newborn's temperature is within the
expected reference range of 36.5° to 37.5° C (97.7° to 99.5° F).
© 2025 All rights reserved
, 2 | Page
Therefore, this finding does not need to be reported to the
provider.
Oxygen saturation is incorrect. The newborn's oxygen saturation is
within the expected reference range of greater than 94%; therefore,
this finding does not need to be reported to the provider.
Central nervous system findings is correct. The newborn is
displaying inconsolability, high-pitched cry, increased muscle tone,
tremors, hyperactive Moro reflex, and excessive sucking. These
findings are manifestations of NAS and should be reported to the
provider.
Gastrointestinal findings is correct. The newborn is displaying
poor feeding and loose stools. These findings are manifestations
of NAS and should be reported to the provider.
Exhibit 1: RN note
@ 0900: Client reports a small amount of bright red blood in their
underwear upon awakening. Client denies contractions or
abdominal pain. External fetal monitor applied.
@0930: Client passed large amount of bright red blood from
vagina. Denies pain. Uterine tone soft and nontender to palpation.
Contraction pattern: no contractions noted. Fetal heart rate
pattern: Fetal heart rate baseline 135/min. Moderate variability. No
decelerations noted.
Exhibit 2: VS
@0900: Temperature 36.2°C (97.2° F)Pulse rate 78/min. Respiratory
rate 20/min. Blood pressure 112/64 mmHg. Fetal heart rate
132/min
@0930: Pulse rate 82/min. Blood pressure 116/60 mmHg. Fetal
heart rate 160/min
Exhibit 3: Medical hx
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G4P3. 30 weeks gestation. Previous pregnancies delivered via
cesarean section Ans: — When generating solutions, inserting a
large bore intravenous catheter is indicated. Clients who have third
trimester vaginal bleeding may experience a sudden hemorrhage
and require fluid resuscitation or the administration of blood
products. The nurse should weigh perineal pads. Weighing
perineal pads after use will provide a more accurate assessment of
the volume of blood loss that the client is experiencing.
When generating solutions, the nurse should not administer
methotrexate or assess for cervical dilation because it is
contraindicated for this client. Methotrexate is an antimetabolite
and folic acid antagonist which destroys rapidly dividing cells. It
can be administered during pregnancy to medically resolve an
ectopic pregnancy during the first trimester. Assessing cervical
dilation is contraindicated for any pregnant client who is
experiencing vaginal bleeding. Manipulation of the cervix during
the examination may result in further damage to the placenta and
compromise the well-being of the client and fetus.
A nurse is assessing the newborn of a client who took selective
serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the
following manifestations should the nurse identify as an indication
of withdrawal from an SSRI?
a. Large for gestational age
b. Hyperglycemia
c. Bradypnea
d. Vomiting Ans: — d. Vomiting
© 2025 All rights reserved
, 4 | Page
Expected manifestations associated with fetal exposure to SSRIs
include irritability, agitation, tremors, diarrhea, and vomiting.
These manifestations typically last 2 days.
A nurse in a family planning clinic is caring for a client who
requests an oral contraceptive. Which of the following findings in
the client's history should the nurse recognize as a
contraindication to oral contraceptives? (Select all that apply)
a. Cholecystitis
b. Hypertension
c. Human papillomavirus
d. Migraine headaches
e. Anxiety disorder Ans: — Cholecystitis, hypertension, and
migraine headaches is correct. A history of gallbladder disease is a
contraindication for the use of oral contraceptives. Hypertension is
a contraindication for the use of oral contraceptives. A history of
migraine headaches is a contraindication for the use of oral
contraceptives.
HPV and anxiety disorder is incorrect. The presence of human
papillomavirus is not a contraindication for the use of oral
contraceptives. The presence of an anxiety disorder is not a
contraindication for the use of oral contraceptives.
A nurse is caring for a newborn.
Exhibit 1: Medical hx
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