ATI Maternal Newborn Intrapartum Complications & Interventions
Exam 4 2026 |Questions |Answers |Rationales
1. A nurse is caring for a client in labor who has a prolapsed umbilical cord.
Which of the following actions should the nurse take first?
A. Administer oxygen via face mask at 10 L/min.
B. Apply sterile saline-soaked towels to the cord.
C. Use a sterile gloved hand to apply pressure to the fetal presenting part.
D. Increase the IV fluid rate.
Answer: C
Rationale: The priority action in a cord prolapse is to relieve pressure on the cord to
maintain fetal oxygenation by manually elevating the presenting part.
2. A client is receiving magnesium sulfate for preterm labor. Which of the
following findings should the nurse report to the provider as a sign of toxicity?
A. Urinary output of 40 mL/hr
B. Presence of deep tendon reflexes
C. Respiratory rate of 10/min
D. Maternal heart rate of 90/min
Answer: C
Rationale: Respiratory depression (less than 12/min) is a classic sign of magnesium
sulfate toxicity. Others include absent DTRs and decreased urinary output.
,3. A nurse is monitoring a client receiving oxytocin for induction. The nurse
notes 6 contractions in a 10-minute period. Which of the following actions is the
priority?
A. Decrease the oxytocin rate by half.
B. Administer terbutaline 0.25 mg subcutaneously.
C. Discontinue the oxytocin infusion.
D. Turn the client to a side-lying position.
Answer: C
Rationale: More than 5 contractions in 10 minutes indicates uterine tachysystole. The
priority action is to stop the oxytocin to prevent fetal distress.
4. Which of the following medications is administered to a client at 30 weeks of
gestation to promote fetal lung maturity?
A. Nifedipine
B. Terbutaline
C. Indomethacin
D. Betamethasone
Answer: D
Rationale: Betamethasone is a glucocorticoid given to stimulate fetal surfactant
production when preterm birth is imminent.
5. A nurse is caring for a client experiencing shoulder dystocia. Which of the
following maneuvers should the nurse implement?
A. Fundal pressure
B. Leopold maneuvers
C. Valsalva maneuver
D. McRoberts maneuver
Answer: D
, Rationale: The McRoberts maneuver (flexing legs against abdomen) helps widen the pelvic
outlet to resolve shoulder dystocia. Fundal pressure is contraindicated.
6. A client at 34 weeks gestation has a positive fetal fibronectin (fFN) test. The
nurse should interpret this as:
A. The client will definitely deliver within 24 hours.
B. The client is at increased risk for preterm labor in the next 1 to 2 weeks.
C. Fetal lung maturity has been achieved.
D. The client has a urinary tract infection.
Answer: B
Rationale: A positive fFN between 24 and 34 weeks indicates an increased risk of preterm
delivery within the next two weeks.
7. A nurse is caring for a client in the second stage of labor. The fetal heart rate
(FHR) shows late decelerations. What is the suspected cause?
A. Fetal head compression
B. Umbilical cord compression
C. Fetal sleep cycle
D. Uteroplacental insufficiency
Answer: D
Rationale: Late decelerations are caused by uteroplacental insufficiency, which results in
inadequate fetal oxygenation during contractions.
8. Which of the following is a contraindication for the administration of
terbutaline?
A. Fetal heart rate of 150/min
B. Maternal blood pressure of 110/70 mmHg
C. History of gestational diabetes
D. Maternal heart rate of 130/min
Answer: D
Exam 4 2026 |Questions |Answers |Rationales
1. A nurse is caring for a client in labor who has a prolapsed umbilical cord.
Which of the following actions should the nurse take first?
A. Administer oxygen via face mask at 10 L/min.
B. Apply sterile saline-soaked towels to the cord.
C. Use a sterile gloved hand to apply pressure to the fetal presenting part.
D. Increase the IV fluid rate.
Answer: C
Rationale: The priority action in a cord prolapse is to relieve pressure on the cord to
maintain fetal oxygenation by manually elevating the presenting part.
2. A client is receiving magnesium sulfate for preterm labor. Which of the
following findings should the nurse report to the provider as a sign of toxicity?
A. Urinary output of 40 mL/hr
B. Presence of deep tendon reflexes
C. Respiratory rate of 10/min
D. Maternal heart rate of 90/min
Answer: C
Rationale: Respiratory depression (less than 12/min) is a classic sign of magnesium
sulfate toxicity. Others include absent DTRs and decreased urinary output.
,3. A nurse is monitoring a client receiving oxytocin for induction. The nurse
notes 6 contractions in a 10-minute period. Which of the following actions is the
priority?
A. Decrease the oxytocin rate by half.
B. Administer terbutaline 0.25 mg subcutaneously.
C. Discontinue the oxytocin infusion.
D. Turn the client to a side-lying position.
Answer: C
Rationale: More than 5 contractions in 10 minutes indicates uterine tachysystole. The
priority action is to stop the oxytocin to prevent fetal distress.
4. Which of the following medications is administered to a client at 30 weeks of
gestation to promote fetal lung maturity?
A. Nifedipine
B. Terbutaline
C. Indomethacin
D. Betamethasone
Answer: D
Rationale: Betamethasone is a glucocorticoid given to stimulate fetal surfactant
production when preterm birth is imminent.
5. A nurse is caring for a client experiencing shoulder dystocia. Which of the
following maneuvers should the nurse implement?
A. Fundal pressure
B. Leopold maneuvers
C. Valsalva maneuver
D. McRoberts maneuver
Answer: D
, Rationale: The McRoberts maneuver (flexing legs against abdomen) helps widen the pelvic
outlet to resolve shoulder dystocia. Fundal pressure is contraindicated.
6. A client at 34 weeks gestation has a positive fetal fibronectin (fFN) test. The
nurse should interpret this as:
A. The client will definitely deliver within 24 hours.
B. The client is at increased risk for preterm labor in the next 1 to 2 weeks.
C. Fetal lung maturity has been achieved.
D. The client has a urinary tract infection.
Answer: B
Rationale: A positive fFN between 24 and 34 weeks indicates an increased risk of preterm
delivery within the next two weeks.
7. A nurse is caring for a client in the second stage of labor. The fetal heart rate
(FHR) shows late decelerations. What is the suspected cause?
A. Fetal head compression
B. Umbilical cord compression
C. Fetal sleep cycle
D. Uteroplacental insufficiency
Answer: D
Rationale: Late decelerations are caused by uteroplacental insufficiency, which results in
inadequate fetal oxygenation during contractions.
8. Which of the following is a contraindication for the administration of
terbutaline?
A. Fetal heart rate of 150/min
B. Maternal blood pressure of 110/70 mmHg
C. History of gestational diabetes
D. Maternal heart rate of 130/min
Answer: D
