LATEST ATI MATERNAL NEWBORN CMS 2025
150+ QUESTIONS WITH CORRECT/ VERIFIED
ANSWERS GRADED A+/A
A nurse in a labor and delivery unit is caring for a client who is in the second stage of labor. Which of the
following actions should the nurse take?
Encourage the client to frequently change positions.
Rationale: During the second stage, frequent position change can promote the descent of the fetus
through the birth canal. The nurse should assist the client in finding optimal positions of comfort which
allow the client to rest between contractions but also enhances expulsive efforts.
A nurse is planning care for a client newborn who was born at 30 weeks gestation. the nurse should plan
to assess the newborn for which of the following potential complications associated with prematurity?
Intraventricular hemorrhage
Rationale: When an infant is born before 34 weeks gestation, the blood vessels in the brain are fragile.
Additionally, premature infants have an impaired coagulation process and fluctuating blood pressure.
Combined, these factors increase the risk of bleeding into the ventricles of the brain and subsequent
neurological damage.
A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse
notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following
actions should the nurse perform?
Prepare equipment needed for newborn resuscitation
,Rationale: The nurse should ensure that all supplies and equipment needed for resuscitation of the
newborn are readily available for every delivery. Endotracheal suctioning is recommended in cases of
meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and
bradycardia after delivery.
A nurse is discussing epidural anesthesia with a client who is receiving oxytocin to induce labor. Which
of the following statements should the nurse make?
"An epidural given too early can prolong labor."
Rationale: Clients who receive anesthesia before the active phase of labor usually find the progression of
their labor slows. The medication depresses the central nervous system, extending the time needed for
the cervix to dilate and efface.
A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For which of the
following findings should the nurse monitor to identify a cervical laceration?
Slow trickle of bright vaginal bleeding and a firm fundus
Rationale: The nurse should monitor for bright red bleeding in the form of a slow trickle, oozing or
outright bleeding, and a firm fundus to identify a cervical laceration.
A nurse is assessing a client who is 3 days postpartum. When examining the client's uterus, which of the
following techniques should the nurse use?
Measure the height of the fundus in finger-breadths in relation to the umbilicus
Rationale: The nurse should measure the height of the fundus in finger-breadths and should expect the
height to decrease 1 finger-breadth in height daily after birth. The fundus should be about 3 finger-
breadths below the umbilicus by the third day postpartum.
,A nurse is planning care for a client who is postpartum. Which of the following strategies should the
nurse include in the plan to prevent bladder distention?
Run water in the sink while the client sits on the toilet
Rationale: Running water in the sink, placing the client's hand in warm water, and using a squeeze bottle
to run water over the client's perineum can assist with spontaneous voiding.
A nurse is providing care to a client who is 2 hours postpartum and is receiving an oxytocin IV. The client
asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse
make?
"The bleeding is minimal until I discontinue your IV medication."
Rationale: The flow of lochia is often scant while receiving oxytocic medication until the effects of the
medication wear off. This can be observed regardless of the administration route of the oxytocic
medication.
A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe
features. Which of the following findings should the nurse identify as a priority?
480 mL urine output in 24 hr
Rationale: When using the urgent vs. non-urgent approach to client care, the nurse should determine
that the priority finding is 480 mL of urine output in 24 hr because the minimum acceptable urine
output in an adult client is 30 mL/hr. this can indicate progression of preeclampsia to preeclampsia with
severe features, which requires immediate intervention. Therefore, this is the priority finding.
, A nurse is assessing a client at 35 weeks gestation who is receiving magnesium sulfate via continuous IV
infusion for severe preeclampsia. Which of the following findings should the nurse report to the
provider?
Urinary output 20 mL/hr
Rationale: the nurse should report a urinary output of 20 mL/hr because this can indicate inadequate
renal perfusion, increasing the risk of magnesium sulfate toxicity. A decrease in urinary output can also
indicate reduced renal perfusion secondary to a worsening of the client's preeclampsia.
A nurse is teaching a client about physiological changes that can occur with menopause. Which of the
following changes should the nurse include?
Stress incontinence
Rationale: The nurse should teach the client that stress incontinence can occur due to the shrinking of
the uterus, vulva, and distal portion of the urethra. Urinary incontinence and uterine displacement can
occur because of common age-related changes but are not necessarily a result of menopause-related
changes.
A nurse is teaching a client who is at 8 weeks gestation and has a uterine fibroid about potential effects
of the fibroid during pregnancy. Which of the following pieces of information should the nurse include?
"The fibroid can increase the risk of postpartum hemorrhage."
Rationale: Uterine fibroids can increase the risk of postpartum hemorrhage due to the increased blood
supply to the uterus, which supports the fibroid.
A nurse is providing education to a client who is at 34 weeks gestation about a non-stress test (NST).
Which of the following pieces of information should the nurse include?
150+ QUESTIONS WITH CORRECT/ VERIFIED
ANSWERS GRADED A+/A
A nurse in a labor and delivery unit is caring for a client who is in the second stage of labor. Which of the
following actions should the nurse take?
Encourage the client to frequently change positions.
Rationale: During the second stage, frequent position change can promote the descent of the fetus
through the birth canal. The nurse should assist the client in finding optimal positions of comfort which
allow the client to rest between contractions but also enhances expulsive efforts.
A nurse is planning care for a client newborn who was born at 30 weeks gestation. the nurse should plan
to assess the newborn for which of the following potential complications associated with prematurity?
Intraventricular hemorrhage
Rationale: When an infant is born before 34 weeks gestation, the blood vessels in the brain are fragile.
Additionally, premature infants have an impaired coagulation process and fluctuating blood pressure.
Combined, these factors increase the risk of bleeding into the ventricles of the brain and subsequent
neurological damage.
A nurse is caring for a client in active labor who has meconium staining of the amniotic fluid. The nurse
notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following
actions should the nurse perform?
Prepare equipment needed for newborn resuscitation
,Rationale: The nurse should ensure that all supplies and equipment needed for resuscitation of the
newborn are readily available for every delivery. Endotracheal suctioning is recommended in cases of
meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and
bradycardia after delivery.
A nurse is discussing epidural anesthesia with a client who is receiving oxytocin to induce labor. Which
of the following statements should the nurse make?
"An epidural given too early can prolong labor."
Rationale: Clients who receive anesthesia before the active phase of labor usually find the progression of
their labor slows. The medication depresses the central nervous system, extending the time needed for
the cervix to dilate and efface.
A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For which of the
following findings should the nurse monitor to identify a cervical laceration?
Slow trickle of bright vaginal bleeding and a firm fundus
Rationale: The nurse should monitor for bright red bleeding in the form of a slow trickle, oozing or
outright bleeding, and a firm fundus to identify a cervical laceration.
A nurse is assessing a client who is 3 days postpartum. When examining the client's uterus, which of the
following techniques should the nurse use?
Measure the height of the fundus in finger-breadths in relation to the umbilicus
Rationale: The nurse should measure the height of the fundus in finger-breadths and should expect the
height to decrease 1 finger-breadth in height daily after birth. The fundus should be about 3 finger-
breadths below the umbilicus by the third day postpartum.
,A nurse is planning care for a client who is postpartum. Which of the following strategies should the
nurse include in the plan to prevent bladder distention?
Run water in the sink while the client sits on the toilet
Rationale: Running water in the sink, placing the client's hand in warm water, and using a squeeze bottle
to run water over the client's perineum can assist with spontaneous voiding.
A nurse is providing care to a client who is 2 hours postpartum and is receiving an oxytocin IV. The client
asks the nurse, "Why is there so little bleeding?" Which of the following responses should the nurse
make?
"The bleeding is minimal until I discontinue your IV medication."
Rationale: The flow of lochia is often scant while receiving oxytocic medication until the effects of the
medication wear off. This can be observed regardless of the administration route of the oxytocic
medication.
A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe
features. Which of the following findings should the nurse identify as a priority?
480 mL urine output in 24 hr
Rationale: When using the urgent vs. non-urgent approach to client care, the nurse should determine
that the priority finding is 480 mL of urine output in 24 hr because the minimum acceptable urine
output in an adult client is 30 mL/hr. this can indicate progression of preeclampsia to preeclampsia with
severe features, which requires immediate intervention. Therefore, this is the priority finding.
, A nurse is assessing a client at 35 weeks gestation who is receiving magnesium sulfate via continuous IV
infusion for severe preeclampsia. Which of the following findings should the nurse report to the
provider?
Urinary output 20 mL/hr
Rationale: the nurse should report a urinary output of 20 mL/hr because this can indicate inadequate
renal perfusion, increasing the risk of magnesium sulfate toxicity. A decrease in urinary output can also
indicate reduced renal perfusion secondary to a worsening of the client's preeclampsia.
A nurse is teaching a client about physiological changes that can occur with menopause. Which of the
following changes should the nurse include?
Stress incontinence
Rationale: The nurse should teach the client that stress incontinence can occur due to the shrinking of
the uterus, vulva, and distal portion of the urethra. Urinary incontinence and uterine displacement can
occur because of common age-related changes but are not necessarily a result of menopause-related
changes.
A nurse is teaching a client who is at 8 weeks gestation and has a uterine fibroid about potential effects
of the fibroid during pregnancy. Which of the following pieces of information should the nurse include?
"The fibroid can increase the risk of postpartum hemorrhage."
Rationale: Uterine fibroids can increase the risk of postpartum hemorrhage due to the increased blood
supply to the uterus, which supports the fibroid.
A nurse is providing education to a client who is at 34 weeks gestation about a non-stress test (NST).
Which of the following pieces of information should the nurse include?
