ATI MATERNAL NEWBORN NURSING WITH NGN QUESTIONS
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1. A nurse is caring for a client who is at 32 weeks of gestation and experiencing mild
gestational hypertension. Which of the following findings should the nurse report to the
provider immediately?
A. Blood pressure of 138/88 mmHg
B. Trace protein in the urine via dipstick
C. Epigastric pain and persistent headache
D. 2+ pitting edema in the lower extremities
ANSWER: C. Epigastric pain and persistent headache
Epigastric pain and a persistent headache are classic warning signs of severe preeclampsia,
indicating impending central nervous system irritability and potential hepatic involvement.
While elevated blood pressure, trace proteinuria, and mild dependent edema are monitored
findings in gestational hypertension, epigastric pain signifies an urgent progression toward
severe disease requiring immediate medical intervention.
2. A nurse is assessing a postpartum client 4 hours following a vaginal delivery. The nurse
notes that the client's fundus is boggy, displaced to the right, and 2 cm above the umbilicus.
What is the priority nursing action?
A. Administer methylergonovine as prescribed.
B. Assist the client to empty her bladder.
C. Perform bimanual compression of the uterus.
D. Increase the rate of the intravenous oxytocin infusion.
ANSWER: B. Assist the client to empty her bladder.
A boggy uterus that is displaced to the right is most frequently caused by a distended bladder,
which prevents the uterus from contracting effectively and increases the risk of postpartum
hemorrhage. Assisting the client to empty her bladder allows the uterus to midline and
contract properly. If fundal tone does not improve after voiding, uterotonic medications would
then be indicated.
3. A nurse is providing discharge instructions to a client who received the Rho(D) immune
globulin injection following the delivery of a newborn. Which of the following statements
by the client indicates an understanding of the teaching?
, A. "This injection protects my baby from developing neonatal jaundice."
B. "I will need to have this medication repeated before I plan any future pregnancies."
C. "This medication will prevent my body from forming antibodies against future Rh-positive
blood cells."
D. "My infant will also need to receive a booster dose of this immune globulin at their two-
month checkup."
ANSWER: C. "This medication will prevent my body from forming antibodies against
future Rh-positive blood cells."
Rho(D) immune globulin is administered to Rh-negative clients to suppress the immune
response and prevent sensitization to Rh-positive fetal blood cells that may have entered the
maternal circulation during delivery. It must be administered after each subsequent
pregnancy involving an Rh-positive fetus, but it does not prevent infant jaundice or require a
booster for the infant.
4. A nurse is monitoring a client in active labor who is receiving an intravenous infusion of
oxytocin. The external fetal monitor tracing reveals late decelerations with minimal
variability. Which of the following actions should the nurse take first?
A. Discontinue the oxytocin infusion.
B. Position the client in a lateral position.
C. Administer oxygen via a nonrebreather mask at 10 L/min.
D. Increase the maintenance intravenous fluid rate.
ANSWER: B. Position the client in a lateral position.
Using the nursing process and evidence-based intrauterine resuscitation protocols,
repositioning the client to a side-lying or lateral position is the priority intervention to relieve
aortocaval compression, improve placental perfusion, and enhance fetal oxygenation.
Although discontinuing oxytocin and administering oxygen are vital secondary steps,
immediate maternal repositioning takes precedence.
5. A nurse is caring for a newborn immediately following delivery. Which of the following
interventions should the nurse perform first to maintain infant thermoregulation?
A. Place the infant under a radiant warmer and dry thoroughly.
B. Administer vitamin K intramuscularly in the vastus lateralis.
C. Apply a knitted cap to the newborn's head.
D. Obtain the initial Apgar score at 1 minute of life.
ANSWER: A. Place the infant under a radiant warmer and dry thoroughly.
Evaporative heat loss is the greatest threat to a newborn immediately after birth. Drying the
infant thoroughly and placing them under a radiant warmer directly mitigates heat loss from
,evaporation and radiation. While hats, vitamin K, and Apgar scoring are essential newborn
care components, drying under a radiant warmer is the immediate priority.
6. A nurse is performing an admission assessment on a client at 36 weeks of gestation who
reports painless, bright red vaginal bleeding. The nurse should recognize that this finding
is indicative of which of the following conditions?
A. Abruptio placentae
B. Placenta previa
C. Uterine rupture
D. Vasa previa
ANSWER: B. Placenta previa
Placenta previa is characterized by painless, bright red vaginal bleeding occurring during the
third trimester as the lower uterine segment thrips and the cervix begins to dilate. In contrast,
abruptio placentae typically presents with painful, dark red bleeding accompanied by uterine
rigidity. Vasa previa involves painless bleeding accompanied by fetal vessel rupture, and
uterine rupture presents with severe tearing pain and shock.
7. A nurse is teaching a prenatal class about danger signs during pregnancy that should be
reported to the provider immediately. Which of the following symptoms should the nurse
include?
A. Mild ankle swelling at the end of the day
B. Increased white vaginal discharge without odor
C. Facial edema and blurred vision
D. Occasional mild Braxton Hicks contractions
ANSWER: C. Facial edema and blurred vision
Facial edema, persistent headache, and blurred vision are cardinal signs of gestational
hypertension progressing to preeclampsia, indicating cerebral edema and vascular changes.
Mild ankle swelling, increased physiological leukorrhea, and irregular Braxton Hicks
contractions are common, benign variations of normal pregnancy.
8. A nurse is caring for a client who is receiving magnesium sulfate via continuous IV
infusion for severe preeclampsia. Which of the following findings indicates magnesium
toxicity and requires immediate cessation of the infusion?
A. Respiratory rate of 10/min
B. Serum magnesium level of 6 mg/dL
C. Urine output of 40 mL/hr
D. Deep tendon reflexes of 2+
ANSWER: A. Respiratory rate of 10/min
, A respiratory rate of 10/min indicates central nervous system depression secondary to
magnesium toxicity, requiring immediate discontinuation of the infusion and administration
of calcium gluconate as the antidote. A therapeutic serum magnesium level ranges from 4 to 8
mg/dL, an output of 40 mL/hr is adequate, and 2+ deep tendon reflexes represent a normal
finding.
9. A nurse is assessing a client who is 2 hours postpartum and notes a trickle of bright red
blood from the vagina, a firm uterine fundus located at the umbilicus, and stable vital
signs. Which of the following conditions should the nurse suspect?
A. Uterine atony
B. Retained placental fragments
C. Cervical or vaginal lacerations
D. Postpartum endometritis
ANSWER: C. Cervical or vaginal lacerations
A continuous trickle of bright red vaginal bleeding in the presence of a firm, contracted
uterine fundus strongly suggests genital tract lacerations, such as of the cervix or vagina.
Uterine atony presents with a boggy or soft fundus. Retained placental fragments typically
present with a boggy fundus and late postpartum hemorrhage, while endometritis manifests
days later with fever and foul-smelling lochia.
10. A nurse is caring for a client in labor who has an epidural block in place. The client's
blood pressure drops from 120/80 mmHg to 82/50 mmHg, and the fetal heart tracing
reveals late decelerations. Which of the following actions should the nurse take first?
A. Administer ephedrine intravenously as prescribed.
B. Position the client in a Trendelenburg position.
C. Administer an IV fluid bolus of lactated Ringer's.
D. Notify the anesthesia provider immediately.
ANSWER: C. Administer an IV fluid bolus of lactated Ringer's.
Sympathetic blockade from an epidural anesthesia frequently leads to maternal hypotension,
which compromises uteroplacental blood flow. The first-line nursing intervention is to expand
intravascular volume rapidly with an IV fluid bolus and position the client laterally.
Ephedrine and anesthesia notification follow rapidly if the hypotension persists.
11. A nurse is reviewing the laboratory results of a client who is at 28 weeks of gestation.
Which of the following findings requires intervention by the nurse?
A. Hemoglobin 10.5 g/dL
B. Hematocrit 33%
C. Blood glucose 135 mg/dL following a 1-hour glucose tolerance test
D. Platelet count 250,000/mm3
AND ANSWERS | VERIFIED AND WELL DETAILED ANSWERS
PLUS RATIONALES | GUARANTEED PASS | LATEST EXAM
UPDATE | EXAM PREP | STUDY GUIDE | PRACTICE TEST |
DOWNLOAD INSTANT PDF
1. A nurse is caring for a client who is at 32 weeks of gestation and experiencing mild
gestational hypertension. Which of the following findings should the nurse report to the
provider immediately?
A. Blood pressure of 138/88 mmHg
B. Trace protein in the urine via dipstick
C. Epigastric pain and persistent headache
D. 2+ pitting edema in the lower extremities
ANSWER: C. Epigastric pain and persistent headache
Epigastric pain and a persistent headache are classic warning signs of severe preeclampsia,
indicating impending central nervous system irritability and potential hepatic involvement.
While elevated blood pressure, trace proteinuria, and mild dependent edema are monitored
findings in gestational hypertension, epigastric pain signifies an urgent progression toward
severe disease requiring immediate medical intervention.
2. A nurse is assessing a postpartum client 4 hours following a vaginal delivery. The nurse
notes that the client's fundus is boggy, displaced to the right, and 2 cm above the umbilicus.
What is the priority nursing action?
A. Administer methylergonovine as prescribed.
B. Assist the client to empty her bladder.
C. Perform bimanual compression of the uterus.
D. Increase the rate of the intravenous oxytocin infusion.
ANSWER: B. Assist the client to empty her bladder.
A boggy uterus that is displaced to the right is most frequently caused by a distended bladder,
which prevents the uterus from contracting effectively and increases the risk of postpartum
hemorrhage. Assisting the client to empty her bladder allows the uterus to midline and
contract properly. If fundal tone does not improve after voiding, uterotonic medications would
then be indicated.
3. A nurse is providing discharge instructions to a client who received the Rho(D) immune
globulin injection following the delivery of a newborn. Which of the following statements
by the client indicates an understanding of the teaching?
, A. "This injection protects my baby from developing neonatal jaundice."
B. "I will need to have this medication repeated before I plan any future pregnancies."
C. "This medication will prevent my body from forming antibodies against future Rh-positive
blood cells."
D. "My infant will also need to receive a booster dose of this immune globulin at their two-
month checkup."
ANSWER: C. "This medication will prevent my body from forming antibodies against
future Rh-positive blood cells."
Rho(D) immune globulin is administered to Rh-negative clients to suppress the immune
response and prevent sensitization to Rh-positive fetal blood cells that may have entered the
maternal circulation during delivery. It must be administered after each subsequent
pregnancy involving an Rh-positive fetus, but it does not prevent infant jaundice or require a
booster for the infant.
4. A nurse is monitoring a client in active labor who is receiving an intravenous infusion of
oxytocin. The external fetal monitor tracing reveals late decelerations with minimal
variability. Which of the following actions should the nurse take first?
A. Discontinue the oxytocin infusion.
B. Position the client in a lateral position.
C. Administer oxygen via a nonrebreather mask at 10 L/min.
D. Increase the maintenance intravenous fluid rate.
ANSWER: B. Position the client in a lateral position.
Using the nursing process and evidence-based intrauterine resuscitation protocols,
repositioning the client to a side-lying or lateral position is the priority intervention to relieve
aortocaval compression, improve placental perfusion, and enhance fetal oxygenation.
Although discontinuing oxytocin and administering oxygen are vital secondary steps,
immediate maternal repositioning takes precedence.
5. A nurse is caring for a newborn immediately following delivery. Which of the following
interventions should the nurse perform first to maintain infant thermoregulation?
A. Place the infant under a radiant warmer and dry thoroughly.
B. Administer vitamin K intramuscularly in the vastus lateralis.
C. Apply a knitted cap to the newborn's head.
D. Obtain the initial Apgar score at 1 minute of life.
ANSWER: A. Place the infant under a radiant warmer and dry thoroughly.
Evaporative heat loss is the greatest threat to a newborn immediately after birth. Drying the
infant thoroughly and placing them under a radiant warmer directly mitigates heat loss from
,evaporation and radiation. While hats, vitamin K, and Apgar scoring are essential newborn
care components, drying under a radiant warmer is the immediate priority.
6. A nurse is performing an admission assessment on a client at 36 weeks of gestation who
reports painless, bright red vaginal bleeding. The nurse should recognize that this finding
is indicative of which of the following conditions?
A. Abruptio placentae
B. Placenta previa
C. Uterine rupture
D. Vasa previa
ANSWER: B. Placenta previa
Placenta previa is characterized by painless, bright red vaginal bleeding occurring during the
third trimester as the lower uterine segment thrips and the cervix begins to dilate. In contrast,
abruptio placentae typically presents with painful, dark red bleeding accompanied by uterine
rigidity. Vasa previa involves painless bleeding accompanied by fetal vessel rupture, and
uterine rupture presents with severe tearing pain and shock.
7. A nurse is teaching a prenatal class about danger signs during pregnancy that should be
reported to the provider immediately. Which of the following symptoms should the nurse
include?
A. Mild ankle swelling at the end of the day
B. Increased white vaginal discharge without odor
C. Facial edema and blurred vision
D. Occasional mild Braxton Hicks contractions
ANSWER: C. Facial edema and blurred vision
Facial edema, persistent headache, and blurred vision are cardinal signs of gestational
hypertension progressing to preeclampsia, indicating cerebral edema and vascular changes.
Mild ankle swelling, increased physiological leukorrhea, and irregular Braxton Hicks
contractions are common, benign variations of normal pregnancy.
8. A nurse is caring for a client who is receiving magnesium sulfate via continuous IV
infusion for severe preeclampsia. Which of the following findings indicates magnesium
toxicity and requires immediate cessation of the infusion?
A. Respiratory rate of 10/min
B. Serum magnesium level of 6 mg/dL
C. Urine output of 40 mL/hr
D. Deep tendon reflexes of 2+
ANSWER: A. Respiratory rate of 10/min
, A respiratory rate of 10/min indicates central nervous system depression secondary to
magnesium toxicity, requiring immediate discontinuation of the infusion and administration
of calcium gluconate as the antidote. A therapeutic serum magnesium level ranges from 4 to 8
mg/dL, an output of 40 mL/hr is adequate, and 2+ deep tendon reflexes represent a normal
finding.
9. A nurse is assessing a client who is 2 hours postpartum and notes a trickle of bright red
blood from the vagina, a firm uterine fundus located at the umbilicus, and stable vital
signs. Which of the following conditions should the nurse suspect?
A. Uterine atony
B. Retained placental fragments
C. Cervical or vaginal lacerations
D. Postpartum endometritis
ANSWER: C. Cervical or vaginal lacerations
A continuous trickle of bright red vaginal bleeding in the presence of a firm, contracted
uterine fundus strongly suggests genital tract lacerations, such as of the cervix or vagina.
Uterine atony presents with a boggy or soft fundus. Retained placental fragments typically
present with a boggy fundus and late postpartum hemorrhage, while endometritis manifests
days later with fever and foul-smelling lochia.
10. A nurse is caring for a client in labor who has an epidural block in place. The client's
blood pressure drops from 120/80 mmHg to 82/50 mmHg, and the fetal heart tracing
reveals late decelerations. Which of the following actions should the nurse take first?
A. Administer ephedrine intravenously as prescribed.
B. Position the client in a Trendelenburg position.
C. Administer an IV fluid bolus of lactated Ringer's.
D. Notify the anesthesia provider immediately.
ANSWER: C. Administer an IV fluid bolus of lactated Ringer's.
Sympathetic blockade from an epidural anesthesia frequently leads to maternal hypotension,
which compromises uteroplacental blood flow. The first-line nursing intervention is to expand
intravascular volume rapidly with an IV fluid bolus and position the client laterally.
Ephedrine and anesthesia notification follow rapidly if the hypotension persists.
11. A nurse is reviewing the laboratory results of a client who is at 28 weeks of gestation.
Which of the following findings requires intervention by the nurse?
A. Hemoglobin 10.5 g/dL
B. Hematocrit 33%
C. Blood glucose 135 mg/dL following a 1-hour glucose tolerance test
D. Platelet count 250,000/mm3
