ATI Maternal Newborn Proctored
Assessment Maternal-Newborn Nursing
Examination Questions, Verified Answers,
and Rationales
1. A nurse is assessing a client at 39 weeks of gestation. Which
finding is the most reliable indicator that labor has begun?
A. Back discomfort
B. Bloody show with regular cervical change
C. Lightening
D. Increased urinary frequency
Answer: B. Bloody show with regular cervical change
Rationale: True labor is confirmed by regular contractions that
produce progressive cervical dilation and effacement, often
accompanied by bloody show.
2. A client is in the active phase of the first stage of labor.
Which assessment requires immediate intervention?
A. Cervical dilation of 6 cm
B. Contractions every 3 minutes lasting 60 seconds
,C. Fetal heart rate of 90 beats/min for 5 minutes
D. Maternal pulse of 88 beats/min
Answer: C. Fetal heart rate of 90 beats/min for 5 minutes
Rationale: Sustained fetal bradycardia indicates fetal
compromise and requires prompt evaluation and intervention.
3. Which maternal hormone is primarily responsible for
stimulating uterine contractions during labor?
A. Estrogen
B. Progesterone
C. Oxytocin
D. Prolactin
Answer: C. Oxytocin
Rationale: Oxytocin stimulates rhythmic uterine contractions
that promote labor progression.
4. A nurse identifies variable fetal heart rate decelerations
during labor. Which action should the nurse perform first?
A. Increase oxytocin infusion
B. Reposition the client
C. Prepare for delivery immediately
D. Encourage pushing
,Answer: B. Reposition the client
Rationale: Variable decelerations commonly result from cord
compression. Maternal repositioning may relieve compression
and improve fetal oxygenation.
5. Which laboratory finding during pregnancy should be
reported immediately?
A. Hemoglobin 11 g/dL
B. Platelets 220,000/mm³
C. Proteinuria with hypertension
D. WBC 12,000/mm³
Answer: C. Proteinuria with hypertension
Rationale: Proteinuria combined with hypertension suggests
preeclampsia, requiring immediate evaluation.
6. A client at 32 weeks reports sudden painless vaginal
bleeding. Which condition is most likely?
A. Placenta previa
B. Placental abruption
C. Uterine rupture
D. Ectopic pregnancy
Answer: A. Placenta previa
, Rationale: Placenta previa typically presents with painless,
bright-red vaginal bleeding in late pregnancy.
7. Which intervention is appropriate for a client receiving
magnesium sulfate?
A. Assess deep tendon reflexes regularly
B. Encourage unrestricted ambulation
C. Restrict fluid intake completely
D. Administer calcium supplements routinely
Answer: A. Assess deep tendon reflexes regularly
Rationale: Diminished reflexes may indicate magnesium
toxicity and require prompt evaluation.
8. Which newborn finding requires immediate intervention?
A. Acrocyanosis
B. Respiratory rate of 72/min with grunting
C. Heart rate of 130/min
D. Flexed posture
Answer: B. Respiratory rate of 72/min with grunting
Rationale: Persistent tachypnea with grunting indicates
respiratory distress requiring prompt assessment.
Assessment Maternal-Newborn Nursing
Examination Questions, Verified Answers,
and Rationales
1. A nurse is assessing a client at 39 weeks of gestation. Which
finding is the most reliable indicator that labor has begun?
A. Back discomfort
B. Bloody show with regular cervical change
C. Lightening
D. Increased urinary frequency
Answer: B. Bloody show with regular cervical change
Rationale: True labor is confirmed by regular contractions that
produce progressive cervical dilation and effacement, often
accompanied by bloody show.
2. A client is in the active phase of the first stage of labor.
Which assessment requires immediate intervention?
A. Cervical dilation of 6 cm
B. Contractions every 3 minutes lasting 60 seconds
,C. Fetal heart rate of 90 beats/min for 5 minutes
D. Maternal pulse of 88 beats/min
Answer: C. Fetal heart rate of 90 beats/min for 5 minutes
Rationale: Sustained fetal bradycardia indicates fetal
compromise and requires prompt evaluation and intervention.
3. Which maternal hormone is primarily responsible for
stimulating uterine contractions during labor?
A. Estrogen
B. Progesterone
C. Oxytocin
D. Prolactin
Answer: C. Oxytocin
Rationale: Oxytocin stimulates rhythmic uterine contractions
that promote labor progression.
4. A nurse identifies variable fetal heart rate decelerations
during labor. Which action should the nurse perform first?
A. Increase oxytocin infusion
B. Reposition the client
C. Prepare for delivery immediately
D. Encourage pushing
,Answer: B. Reposition the client
Rationale: Variable decelerations commonly result from cord
compression. Maternal repositioning may relieve compression
and improve fetal oxygenation.
5. Which laboratory finding during pregnancy should be
reported immediately?
A. Hemoglobin 11 g/dL
B. Platelets 220,000/mm³
C. Proteinuria with hypertension
D. WBC 12,000/mm³
Answer: C. Proteinuria with hypertension
Rationale: Proteinuria combined with hypertension suggests
preeclampsia, requiring immediate evaluation.
6. A client at 32 weeks reports sudden painless vaginal
bleeding. Which condition is most likely?
A. Placenta previa
B. Placental abruption
C. Uterine rupture
D. Ectopic pregnancy
Answer: A. Placenta previa
, Rationale: Placenta previa typically presents with painless,
bright-red vaginal bleeding in late pregnancy.
7. Which intervention is appropriate for a client receiving
magnesium sulfate?
A. Assess deep tendon reflexes regularly
B. Encourage unrestricted ambulation
C. Restrict fluid intake completely
D. Administer calcium supplements routinely
Answer: A. Assess deep tendon reflexes regularly
Rationale: Diminished reflexes may indicate magnesium
toxicity and require prompt evaluation.
8. Which newborn finding requires immediate intervention?
A. Acrocyanosis
B. Respiratory rate of 72/min with grunting
C. Heart rate of 130/min
D. Flexed posture
Answer: B. Respiratory rate of 72/min with grunting
Rationale: Persistent tachypnea with grunting indicates
respiratory distress requiring prompt assessment.
