ATI RN MATERNAL NEWBORN A 2026
ACTUAL EXAM TEST GRADED A+ WITH
DETAILED RATIONALES
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 Correct Answer d. Vomiting
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 Correct Answer 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
@1600: Apgar score 9 at 1 min and 9 at 5 min. Birth weight
4,706g (10lb 6oz). Gestational age 40 weeks. Difficult vaginal
birth with shoulder dystocia.
Exhibit 2: RN note
@1700: Newborn is active and moves all extremities except for
right arm. No spontaneous movement of the right arm noted.
Right arm remains at side during Moro reflex.
,Exhibit 3: Physical Exam
Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted.
Elbow extended. Forearm pronated with wrist and fingers flexed.
Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's
palsy) paralysis. Correct Answer Educate the parents to begin
range of motion exercises on the affected arm after 1 week is
indicated. Passive ROM exercises of the arm are indicated to
restore function of the extremity. The initiation of these exercises
is delayed for approximately 1 week to prevent additional injury to
the brachial plexus.
Assess for grasp reflex in the affected extremity is indicated. With
Erb-Duchenne paralysis, only the upper arm is affected. The
function of the wrists and fingers should be unaffected; the nurse
should assess for a palmar grasp reflex.
Immobilize the arm across the abdomen by pinning the newborn's
sleeve to their shirt is indicated. Intermittent immobilization of the
affected arm across the newborn's abdomen can be achieved by
pinning the sleeve to the shirt.
Instruct parents to limit physical handling for 2 weeks is
contraindicated. Parents and guardians should participate in the
physical care of their newborn to increase parental-infant
attachment. Providing education and practice opportunities for the
parents will decrease their fears of injuring the newborn and
increase confidence and bonding.
, A nurse is admitting a client to the labor and delivery unit when
the client states, "My water just broke." Which of the following
interventions is the nurse's priority?
a. Perform Nitrazine testing
b. Assess the fluid
c. Check cervical dilation
d. Begin FHR monitoring Correct Answer d. Begin FHR
monitoring
The greatest risk to the client and their fetus following a rupture of
membranes is umbilical cord prolapse. The nurse should monitor
the fetus closely to ensure well-being. Therefore, this is the
priority action the nurse should take.
A nurse in an antepartum clinic is providing care for a client who is
at 26 weeks of gestation. Upon reviewing the client's medical
record, which of the following findings should the nurse report to
the provider? (Click on the "Exhibit" button for additional
information about the client. There are three tabs that contain
separate categories of data.)
Exhibit 1: Graphic Record
Blood pressure 130/78 mm Hg, Respiratory rate 20/min, Heart
rate 90/min
ACTUAL EXAM TEST GRADED A+ WITH
DETAILED RATIONALES
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 Correct Answer d. Vomiting
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 Correct Answer 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
@1600: Apgar score 9 at 1 min and 9 at 5 min. Birth weight
4,706g (10lb 6oz). Gestational age 40 weeks. Difficult vaginal
birth with shoulder dystocia.
Exhibit 2: RN note
@1700: Newborn is active and moves all extremities except for
right arm. No spontaneous movement of the right arm noted.
Right arm remains at side during Moro reflex.
,Exhibit 3: Physical Exam
Absent Moro reflex noted in right arm.
Right shoulder and arm are internally rotated and adducted.
Elbow extended. Forearm pronated with wrist and fingers flexed.
Diagnosis: Brachial plexus injury resulting in Erb-Duchenne (Erb's
palsy) paralysis. Correct Answer Educate the parents to begin
range of motion exercises on the affected arm after 1 week is
indicated. Passive ROM exercises of the arm are indicated to
restore function of the extremity. The initiation of these exercises
is delayed for approximately 1 week to prevent additional injury to
the brachial plexus.
Assess for grasp reflex in the affected extremity is indicated. With
Erb-Duchenne paralysis, only the upper arm is affected. The
function of the wrists and fingers should be unaffected; the nurse
should assess for a palmar grasp reflex.
Immobilize the arm across the abdomen by pinning the newborn's
sleeve to their shirt is indicated. Intermittent immobilization of the
affected arm across the newborn's abdomen can be achieved by
pinning the sleeve to the shirt.
Instruct parents to limit physical handling for 2 weeks is
contraindicated. Parents and guardians should participate in the
physical care of their newborn to increase parental-infant
attachment. Providing education and practice opportunities for the
parents will decrease their fears of injuring the newborn and
increase confidence and bonding.
, A nurse is admitting a client to the labor and delivery unit when
the client states, "My water just broke." Which of the following
interventions is the nurse's priority?
a. Perform Nitrazine testing
b. Assess the fluid
c. Check cervical dilation
d. Begin FHR monitoring Correct Answer d. Begin FHR
monitoring
The greatest risk to the client and their fetus following a rupture of
membranes is umbilical cord prolapse. The nurse should monitor
the fetus closely to ensure well-being. Therefore, this is the
priority action the nurse should take.
A nurse in an antepartum clinic is providing care for a client who is
at 26 weeks of gestation. Upon reviewing the client's medical
record, which of the following findings should the nurse report to
the provider? (Click on the "Exhibit" button for additional
information about the client. There are three tabs that contain
separate categories of data.)
Exhibit 1: Graphic Record
Blood pressure 130/78 mm Hg, Respiratory rate 20/min, Heart
rate 90/min
