ATI RN Maternal Newborn A ACTUAL EXAM \UPDATED
QUESTIONS AND ACCURATE DETAILED ANSWERS
\VERIFIED 100% GRADED A+\BRAND NEW 2025-2026
A nurse is caring for a Educate the parents to begin range of motion
newborn. exercises on the affected arm after 1 week is indicated.
Passive ROM exercises of the arm are indicated to
Exhibit 1: Medical hx
restore function of the extremity. The initiation of these
@1600: Apgar score 9 at 1
exercises is delayed for approximately 1 week to
min and 9 at 5 min. Birth
prevent additional injury to the brachial plexus.
weight 4,706g (10lb 6oz).
Assess for grasp reflex in the affected extremity is
Gestational age 40 weeks.
indicated. With Erb-Duchenne paralysis, only the upper
Difficult vaginal birth with
arm is affected. The function of the wrists and fingers
shoulder dystocia. should be unaffected; the nurse should assess for a palmar grasp
reflex.
Exhibit 2: RN note Immobilize the arm across the abdomen by pinning the
@1700: Newborn is active and newborn's sleeve to their shirt is indicated. Intermittent
moves all extremities except immobilization of the affected arm across the
for right arm. No newborn's abdomen can be achieved by pinning the
spontaneous movement of sleeve to the shirt.
the right arm noted. Right Instruct parents to limit physical handling for 2 weeks is
arm remains at side during contraindicated. Parents and guardians should
Moro reflex. participate in the physical care of their newborn to
increase
Exhibit 3: Physical Exam parental-infant attachment. Providing education and
Absent Moro reflex noted in practice opportunities for the parents will decrease their
right arm. fears of injuring the newborn and increase confidence
Right shoulder and arm are
and bonding.
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.
,A nurse is admitting a d. Begin FHR monitoring
client to the labor and
delivery unit when the The greatest risk to the client and their fetus following a rupture
of membranes is
client states, "My water
umbilical cord prolapse. The nurse should monitor the
just broke." Which of the
fetus closely to ensure well- being. Therefore, this is the
following interventions is the
priority action the nurse should take.
nurse's priority?
a. Perform Nitrazine testing
b. Assess the fluid
c. Check cervical dilation
Begin FHR monitoring
d.
A nurse is reviewing the a. Hemoglobin 10 g/dL
laboratory results for a
A hemoglobin level of 10g/dL is below the expected reference
client who is at 10 weeks
range of greater than 11g/dL for a client who is pregnant. The
gestation. Which of the nurse should report this laboratory finding to the provider.
following laboratory
findings should the nurse
report to the provider?
a. Hemoglobin 10 g/dL
b. WBC count 15,000/mm^3
c. RBC count 5.8
million/mm^3
d. Hematocrit 34%
,A nurse in an antepartum d. Fundal height measurement
clinic is providing care for a
client who is at 26 weeks of A fundal height measurement of 30 cm should be
gestation. Upon reviewing reported to the provider. Fundal height should be
the client's measured in centimeters and is the same as the
medical record, which of number of gestational weeks plus or minus 2 weeks
the following findings should from 18 to 32 weeks gestation. Therefore, the nurse
the nurse report to the should report this finding to the provider.
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
Exhibit 2: Diagnostic
ResultsHemoglobin 12 g/dL,
Hematocrit 34%, 1-hr
glucose
tolerance test 120 mg/dL
Exhibit 3: Progress Notes
Fundal height 30 cm, Good
fetal
movement, Not experiencing
headache, dizziness, blurred
vision, or vaginal
bleeding, Fetal heart rate
110/min
a. 1-hr glucose tolerance test
b. Hematocrit
c. Fundal height measurement
d. Fetal heart rate (FHR)
, A nurse is caring for a Upon recognizing and analyzing newborn findings of
newborn who is 48 hours old. temperature below the
expected range, respiratory rate above the expected
Exhibit 1: VS range, and hypoglycemia, the nurse's priority hypothesis
Day 2, 0900: Heart rate is that this newborn is most likely experiencing cold
174/min, Respiratory rate stress. It is important to generate solutions and take
88/min, Temperature 36.1° C actions that address cold stress.
(97.0° F), Oxygen saturation Therefore, the nurse should monitor the newborn's
97% on room air temperature and glucose levels because a newborn
experiencing cold stress is at risk for developing
Exhibit 2: Diagnostic metabolic acidosis. To evaluate the client's response to
Results Day 1, 0800: these interventions, the nurse should monitor the
Newborn results newborn's temperature and glucose levels.
Blood type: A+, Urine
toxicology screen: positive
marijuana
Day 2, 0800: Newborn results,
Total
bilirubin 10 mg/dL (1.0 to 12.0
mg/dL)
Day 2, 0915: Blood
glucose: 38 mg/dL
(expected value greater
than 40 to 45 gm/dL
Exhibit 3: RN Notes
Day 2, 0900: Newborn
awake, alert, and crying.
Loosely wrapped in one
blanket.
Mild tremors noted. Yellow
discoloration of mucus
membranes and sclera
noted.
Respirations 88/min, no
retractions,
grunting, or nasal flaring
noted. Diaper changed
for small amount of urine
and transitional stool.
QUESTIONS AND ACCURATE DETAILED ANSWERS
\VERIFIED 100% GRADED A+\BRAND NEW 2025-2026
A nurse is caring for a Educate the parents to begin range of motion
newborn. exercises on the affected arm after 1 week is indicated.
Passive ROM exercises of the arm are indicated to
Exhibit 1: Medical hx
restore function of the extremity. The initiation of these
@1600: Apgar score 9 at 1
exercises is delayed for approximately 1 week to
min and 9 at 5 min. Birth
prevent additional injury to the brachial plexus.
weight 4,706g (10lb 6oz).
Assess for grasp reflex in the affected extremity is
Gestational age 40 weeks.
indicated. With Erb-Duchenne paralysis, only the upper
Difficult vaginal birth with
arm is affected. The function of the wrists and fingers
shoulder dystocia. should be unaffected; the nurse should assess for a palmar grasp
reflex.
Exhibit 2: RN note Immobilize the arm across the abdomen by pinning the
@1700: Newborn is active and newborn's sleeve to their shirt is indicated. Intermittent
moves all extremities except immobilization of the affected arm across the
for right arm. No newborn's abdomen can be achieved by pinning the
spontaneous movement of sleeve to the shirt.
the right arm noted. Right Instruct parents to limit physical handling for 2 weeks is
arm remains at side during contraindicated. Parents and guardians should
Moro reflex. participate in the physical care of their newborn to
increase
Exhibit 3: Physical Exam parental-infant attachment. Providing education and
Absent Moro reflex noted in practice opportunities for the parents will decrease their
right arm. fears of injuring the newborn and increase confidence
Right shoulder and arm are
and bonding.
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.
,A nurse is admitting a d. Begin FHR monitoring
client to the labor and
delivery unit when the The greatest risk to the client and their fetus following a rupture
of membranes is
client states, "My water
umbilical cord prolapse. The nurse should monitor the
just broke." Which of the
fetus closely to ensure well- being. Therefore, this is the
following interventions is the
priority action the nurse should take.
nurse's priority?
a. Perform Nitrazine testing
b. Assess the fluid
c. Check cervical dilation
Begin FHR monitoring
d.
A nurse is reviewing the a. Hemoglobin 10 g/dL
laboratory results for a
A hemoglobin level of 10g/dL is below the expected reference
client who is at 10 weeks
range of greater than 11g/dL for a client who is pregnant. The
gestation. Which of the nurse should report this laboratory finding to the provider.
following laboratory
findings should the nurse
report to the provider?
a. Hemoglobin 10 g/dL
b. WBC count 15,000/mm^3
c. RBC count 5.8
million/mm^3
d. Hematocrit 34%
,A nurse in an antepartum d. Fundal height measurement
clinic is providing care for a
client who is at 26 weeks of A fundal height measurement of 30 cm should be
gestation. Upon reviewing reported to the provider. Fundal height should be
the client's measured in centimeters and is the same as the
medical record, which of number of gestational weeks plus or minus 2 weeks
the following findings should from 18 to 32 weeks gestation. Therefore, the nurse
the nurse report to the should report this finding to the provider.
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
Exhibit 2: Diagnostic
ResultsHemoglobin 12 g/dL,
Hematocrit 34%, 1-hr
glucose
tolerance test 120 mg/dL
Exhibit 3: Progress Notes
Fundal height 30 cm, Good
fetal
movement, Not experiencing
headache, dizziness, blurred
vision, or vaginal
bleeding, Fetal heart rate
110/min
a. 1-hr glucose tolerance test
b. Hematocrit
c. Fundal height measurement
d. Fetal heart rate (FHR)
, A nurse is caring for a Upon recognizing and analyzing newborn findings of
newborn who is 48 hours old. temperature below the
expected range, respiratory rate above the expected
Exhibit 1: VS range, and hypoglycemia, the nurse's priority hypothesis
Day 2, 0900: Heart rate is that this newborn is most likely experiencing cold
174/min, Respiratory rate stress. It is important to generate solutions and take
88/min, Temperature 36.1° C actions that address cold stress.
(97.0° F), Oxygen saturation Therefore, the nurse should monitor the newborn's
97% on room air temperature and glucose levels because a newborn
experiencing cold stress is at risk for developing
Exhibit 2: Diagnostic metabolic acidosis. To evaluate the client's response to
Results Day 1, 0800: these interventions, the nurse should monitor the
Newborn results newborn's temperature and glucose levels.
Blood type: A+, Urine
toxicology screen: positive
marijuana
Day 2, 0800: Newborn results,
Total
bilirubin 10 mg/dL (1.0 to 12.0
mg/dL)
Day 2, 0915: Blood
glucose: 38 mg/dL
(expected value greater
than 40 to 45 gm/dL
Exhibit 3: RN Notes
Day 2, 0900: Newborn
awake, alert, and crying.
Loosely wrapped in one
blanket.
Mild tremors noted. Yellow
discoloration of mucus
membranes and sclera
noted.
Respirations 88/min, no
retractions,
grunting, or nasal flaring
noted. Diaper changed
for small amount of urine
and transitional stool.
