Preview Extract
ATI MATERNITY NEWBORN PRACTICE 2023/2024 AGRADED A LATEST
VERSION
1. A charge nurse on the postpartum unit is observing a newly licensed nurse who is
preparing to administer pain medication to a client. The charge nurse should intervene when
the newly licensed nurse uses which of the following secondary id to identify the client?
Answer: The client's room number
Rationale: Using the client's room number as a secondary identifier is not considered reliable
or sufficient for accurate identification. Relying on room numbers alone can lead to errors
and risks administering medication to the wrong patient. It's essential to use primary
identifiers like the client's full name and date of birth to ensure proper patient identification
and safe medication administration.
2. A nurse is providing discharge teaching to a patient whose newborn has just had a
circumcision. Which of the following instructions should the nurse include?
Answer: Apply slight pressure with a sterile gauze pad for mild bleeding
Rationale: Nurse should instruct client to attempt to stop mild bleeding by applying pressure
with sterile gauze. If bleeding continues the client should notify the provider.
3. A nurse is teaching about effective breastfeeding to a client who is 3 days postpartum.
Which of the following information should the nurse include?
Answer: Your newborn should appear content after feeding
Rationale: If the baby is not content after feeding signs of hunger are rooting, sucking on the
hands or crying because they might not be emptying the breasts during feeding completely
4. A nurse planning care for a client who is in labor and is requesting epidural anesthesia for
pain control. Which of the following actions should the nurse include in the plan of care?
Answer: Monitor the clients B/P every 5 min following the first dose of anesthetic solution
Rationale: The nurse should plan to obtain a baseline blood pressure prior to the initiation of
anesthetic solution. The nurse should then continue to monitor the client's blood pressure
every 5 to 10 min to assess for maternal hypotension caused by the anesthetic solution
5. A nurse is teaching a new mother how to use a bulb syringe to suction her newborn's
secretions. Which of the following instructions should the nurse include?
Answer: Stop suctioning when the newborn cry sounds clear
Rationale: Nurse should instruct client to stop suctioning when cry no longer sounds like it is
coming through a bubble of fluid or mucus
6. A nurse is assessing a client who is 12hr postpartum. The client's fundus is two finger
breadths above the umbilicus deviated to the right of the midline, and less firm than
previously noted. Which of the following actions should the nurse take?
Answer: Assist the client to the bathroom to void
Rationale: A dissented bladder can cause the uterus from contracting and can cause uterine
atony. Therefore, the nurse should assist the client to void.
7. A nurse is reviewing the medical record at 1800 for a client who is at 34wks gestation.
Based in the chart findings and documentation the nursing plan of care should include which
of the following actions?
Answer: Administer terbutaline
Rationale: Administer terbutaline to stop contractions because the lab results indicate that the
fetus's lungs are not mature enough for delivery
8. A nurse is assessing a full-term newborn 15min after birth. Which of the following findings
requires intervention by the nurse?
Answer: Respiratory rate of 18/min
Rationale: First 30 min's of a newborns life the rest rate can range from 20-100/min. A resp.
rate this low at the time requires further evaluation and intervention by the nurse
9. A nurse us assessing a client who is at 26wks gestation. Which of the following clinical
manifestations should the nurse report to the provider?
Answer: Decreased urine output
Rationale: Increased B/P, proteinuria and decreased fetal activity can be indication of
preeclampsia and should be notified to the provider
10. A nurse is providing teaching to a client about the physiological changes that occur during
pregnancy. The client is at 10 weeks of gestation and has a BMI w/in the expected reference
range. Which of the following client statements indicate an understanding of the teaching?
Answer: "I will likely need to use alternative positions for sexual intercourse"
Rationale: The weight of the pregnancy will change positions of sexual intercourse therefore
understanding physiological changes during pregnancy
11. A nurse in a woman health clinic is providing teaching about nutritional intake to a client
who is at 8wks of gestation. The nurse should instruct the client to increase her daily intake of
which of the following nutrients?
Answer: Iron
Rationale: For the woman who are pregnant, it is 27 mg/day. the recommendations for
woman not pregnancy is 15/mg day, for women younger than 19 yr old and 18 mg/day for
women between the ages of 19 and 50 years old.
12. A nurse is assessing a client who is in active labor and notes early decelerations in the
FHR on the monitor tracing. The client is at 39 weeks of gestation and is receiving a
continuous IV infusion of oxytocin. Which of the following actions should the nurse take?
Answer: Continue monitoring the client
Rationale: Early decelerations are due to fetal head during contractions, vaginal
examinations and pushing during the second stage of labor. They are ok and normal
13. A nurse is caring for a newborn who was transferred to the nursery 30 min after delivery.
Which of the following actions should the nurse take first?
Answer: Verify the newborn's ID
Rationale: For safety / risk reduction
14. A nurse is providing education about the family bonding to parents who recently adopted
a newborn. The nurse should make which of the following suggestions to aid the family 7-yr
old in accepting the new family member?
Answer: Obtain a gift from the newborn to present to the sibling
Rationale: The nurse should suggest obtaining a gift from the newborn to present to the
sibling. This helps the older child feel included and valued, creates positive associations with
the newborn, and eases the transition by fostering a sense of excitement and acceptance
towards the new family member.
15. A nurse is teaching a client who has pre-gestational type 1 DM about management during
pregnancy. Which of the following statements by the client indicates an understanding of the
teaching?
Answer: "I will continue to take my insulin if I experience n/v"
Rationale: Teach the client to continue to take insulin as prescribed during illness to prevent
hypoglycemic and hyperglycemic episodes
16. A nurse is providing discharge teaching to a client who is postpartum. For which of the
following clinical manifestations should the nurse instruct the client to monitor and report to
the provider?
Answer: Unilateral breast pain
Rationale: Can indicate mastitis an infection of the breast tissue s/s are chills, fever, malaise
and unilateral breast pain
17. A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which
of the following findings is an adverse effect of this medication?
Answer: HTN
Rationale: Carboprost is a vasoconstrictor that can cause hypertension
18. A nurse is caring for a client who is in labor and reports increasing rectal pressure. She is
experiencing contractions 2-3 mins apart each lasting 80-90 seconds and a vaginal
examination reveals that her cervix is dilated to 9cm. The nurse should identify that the client
is in which of the following phases of labor?
Answer: Transition
Rationale: Based on the client's reported symptoms and cervical dilation of 9cm, she is in the
transition phase of labor. Transition is characterized by strong and frequent contractions,
intense rectal pressure, and cervical dilation from 8 to 10cm. It is the final phase of the first
stage of labor before the onset of the second stage, which involves pushing and delivery of
the baby.
19. A nurse is teaching clients in a prenatal class about the importance of taking folic acid
during pregnancy. The nurse should instruct the clients to consume an adequate amount of
folic acid from various sources to precent which of the following fetal abnormalities?
Answer: Neural tube defect
Rationale: folic acid sources include fortified cereals, grain products, oranges, artichokes,
liver, broccoli and asparagus
20. A school nurse is providing teaching to an adolescent about levonorgestrel contraception.
Which of the following information should the nurse include in the teaching?
Answer: You should take the medication w/in 72 hrs following unprotected sexual
intercourse
Rationale: Considered the emergency contraceptive which inhibits ovulation to prevent
conception
21. A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which
of the following techniques should the nurse use to help minimize the pain of the procedure
for the newborn?
Answer: Place the newborn skin to skin on the mothers chest
Rationale: To decrease the newborn's pain level and anxiety, this should be implemented
before, during, and after the procedure.
22. A nurse is assessing a newborn who is 12hr old. Which of the following clinical s/s
requires intervention by the nurse?
Answer: Substernal chest retractions while sleeping
Rationale: Can indicate rest distress syndrome in the newborn
23. A nurse is caring for a client who is at 40 weeks of gestation and is in early labor. The
client has a platelet count of 75,000/mm3 and is requesting pain relief. Which of the
following treatment modalities should the nurse anticipate?
Answer: Attention-focusing
Rationale: Attention-focusing and distraction techniques are types of non-pharmacological
care that are effective in receiving labor pain
24. A nurse is providing discharge teaching to a client who had a C-section birth 3 days ago.
Which of the following instructions should the nurse include?
Answer: You can still become pregnancy if you are breastfeeding
Rationale: Breastfeeding does not prevent ovulation, nurse should discuss contraception that
is safe to use while breastfeeding.
25. A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which
of the following s/s should the nurse expect?
Answer: Vaginal pressure
Rationale: The nurse should expect a client who has a vaginal hematoma to report pressure
in the vagina due to the blood that lead into the tissues
26. A nurse is caring for a client who has recently experienced a perinatal death. Which of the
following statements should the nurse make to the client?
Answer: "I’m sad for you"
Rationale: The nurse is offering empathy to the client to facilitate further communication
about the perinatal death
27. A nurse is speaking with a client who is trying to make a decision about uterine tube
occlusion. The client asks what effects will this procedure have on my sec life? Which of the
following responses should the nurse make?
Answer: This process should have no effect on your sexual performance or adequacy
Rationale: The nurse should respond, "This process should have no effect on your sexual
performance or adequacy." This assures the client that uterine tube occlusion does not impact
sexual function, desire, or satisfaction, as it is purely a method of contraception and does not
affect hormonal balance or sexual health.
28. A nurse is teaching a group parents about newborn safety. Which of the following
statements by a patent indicates an understanding of the teaching?
Answer: I will dress my baby in flame retardant clothing
Rationale: The parents should dress their newborns in flame-retardant clothing to prevent
injury
29. 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?
Answer: Begin FHR monitoring
Rationale: Initiating fetal heart rate (FHR) monitoring is the nurse's priority in this scenario
because the rupture of membranes (water breaking) can increase the risk of umbilical cord
prolapse or compression, which could compromise fetal oxygenation and circulation. FHR
monitoring allows for the immediate assessment of fetal well-being and the early detection of
any signs of fetal distress or complications related to the rupture of membranes. This enables
prompt intervention to ensure the safety of both the mother and the baby during labor and
delivery.
30. A nurse is providing teaching for a client who gave birth 2 hr ago about the facility policy
for newborn safety. Which of the following client statements indicates an understanding of
the teaching?
Answer: The person who come sin to take my baby's pictures will be wearing a photo ID
badge
Rationale: All personnel working on the unit should be wearing a photo identification badge.
The nurse should teach the mother to never allow anyone who is not wearing an identification
badge to come in contact with her newborn.
31. A nurse is caring for a client who has uterine hypotonicity and is experiencing postpartum
haemorrhage. Which of the following actions is the nurses priority?
Answer: Massage the client's fundus
Rationale: Uterine hypotonicity and postpartum haemorrhage indicate that his client is at the
greatest risk for hypovolemic shock. The can compromise the perfusion to the clients vital
organs, causing death to occur. Therefore, the nurses priority is to massage the clients fundus
in order to minimize blood loss.
32. A nurse is assessing four newborns. Which of the following findings should the nurse
report to the provider?
Answer: A newborn who is 18 hr old and has an axillary temp of 37.7 (99.9F)
Rationale: The nurse should report a newborn who is 18 hours old and has an axillary
temperature of 37.7°C (99.9°F). This elevated temperature may indicate an infection or other
medical condition requiring prompt evaluation and intervention, as newborns are particularly
vulnerable to complications from even mild hyperthermia.
33. A nurse is assessing a client who is at 38 weeks gestation during a weekly prenatal visit.
Which of the following findings should the nurse report to the provider?
Answer: Weight gain of 2.2 kg (4.8lbs)
Rationale: A week is above reference range and could indicate complications Math
34. A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is in
preterm labor. Available is 20g magnesium sulfate in 500ml of dextrose 5% in water (D5W).
The nurse should set the IV infusion pump to administer how many ml/hr? (round to whole
number)
Answer: 50ml/hr
Rationale: To administer 2g/hr of magnesium sulfate, the nurse needs to deliver 50 ml/hr of
the solution. This is calculated by using the ratio from the available concentration (20g in
500ml), which equates to 1g in 25ml, thus 2g requires 50ml.
35. A nurse is assessing a newborn who was delivered vaginally and experienced a tight
nuchal cord. Which of the following clinical manifestations should the nurse expect?
Answer: Petechiae over the head
Rationale: Nuchal cord or the umbilical cord being wrapped tightly around the neck, can
cause bruising and petechiae over the face, head and neck
36. A nurse is caring for a client who is to rec oxytocin to augment her labor. Which of the
following findings contraindicates the initiation of the oxytocin infusion and should be
reported to the provider?
Answer: Late decelerations
Rationale: Late decelerations are a concerning fetal heart rate pattern indicating
uteroplacental insufficiency, where the baby's oxygen supply is compromised during
contractions. This finding contraindicates the initiation of oxytocin infusion because oxytocin
can further stress the fetus by increasing the frequency and intensity of contractions,
potentially worsening late decelerations and leading to fetal distress. Therefore, it is crucial to
report this finding to the provider promptly to assess fetal well-being and consider alternative
management options for labor augmentation.
37. A nurse is caring for a client who is at 22 weeks gestation and reports concern about the
blotchy hyper pigmentation of her forehead. Which of the following actions should the nurse
take?
Answer: Explain to the client this is an expected occurrence
Rationale: Melasma, also referred to as the mask of pregnancy, is a blotchy, brown
hyperpigmentation of the skin over the cheeks, nose, and for head. It is seen most often in
dark-skinned women and is caused by an increase in melanotrin during pregnancy. This
condition appears after 16 weeks of gestation and increases gradually until delivery for 50 to
70 % of women. Nurse should reassure the client that this is an expected occurrence which
usually fades after delivery.
38. A nurse is assessing FHR for a client who is pregnancy. The nurse has determined as left
occipital anterior (LOA). To which of the following areas of the clients abdomen should the
nurse apply the ultrasound transducer in order to assess the PMI of the fetal heart?
Answer: Left lower quadrant
Rationale: The fetal heart tones of a fetus in the occipital anterior position are best heard in
the left lower quadrant.
39. A nurse in a provider's office is reviewing the medical record of a client who is in her first
trimester of pregnancy. Which of the following findings should the nurse identify as a risk
factor for the development of preeclampsia?
Answer: Pregestational DM
Rationale: Is a risk factor for developing preeclampsia. Other risk include, preexisting HTN,
renal disease, systemic lupus erythematosus, and rheumatoid arthritis.
40. A nurse is discussing the differences between true labor and false labor with a group of
expectant parents. Which of the following characteristics should the nurse include when
discussing true labor?
Answer: Contractions become stronger with walking
Rationale: In true labor, contractions typically become stronger and more regular over time,
regardless of activity level. Walking may intensify contractions in true labor due to the
increased gravitational force on the uterus, but the primary characteristic distinguishing true
labor is the progressive increase in contraction intensity and frequency as labor progresses.
41. A nurse is developing an educational program for adolescents about nutrition during the
third trimester of pregnancy. Which of the following statements should the nurse include in
the program?
Answer: "Consume three to four servings of dairy each day"
Rationale: In the third trimester of pregnancy, adequate calcium intake is crucial for fetal
bone development and maternal bone health. Dairy products are excellent sources of calcium,
making it important for adolescents to consume three to four servings daily to meet these
increased nutritional needs.
42. A nurse is performing a vaginal exam on a client who is in labor and reports severe
pressure and pain in the lower back. he nurse notes that the fetal head is in a posterior
position. The nurse should identify that which of the following is the best non-pharm
intervention to perform to relieve the client's discomfort?
Answer: Counter-pressure
Rationale: According to evidence-based practice, counter pressure is the best
nonpharmacological technique to use when relieving the clients discomfort from the fetus
being in a posterior position because this intervention lifts the fetal head off of the spinal
nerve.
43. A nurse is assessing a late preterm newborn. Which of the following clinical
manifestation is an indication of hypoglycemia?
Answer: Respiratory distress
Rationale: Late preterm newborns are at increased risk for hypoglycaemia due to decreased
glycogen stores and immature insulin secretion, leading to symptoms such as respiratory
distress. Other manifestations include abnormal cry, jitteriness, lethargy, poor feeding, apnea,
and seizures.
44. A nurse is performing a physical assessment of a newborn upon admission to the nursery.
Which of the following signs or symptoms should the nurse expect
Answer: Creases over two thirds of the soles of the feet, molding of the head, lanugo on the
shoulders
Rationale: In a full-term newborn, the nurse should expect to find physical signs such as
creases over two-thirds of the soles of the feet, molding of the head due to passage through
the birth canal, and lanugo on the shoulders, which is fine, downy hair typically present at
birth. These findings are normal indicators of a newborn's maturity and typical birth process.
45. A nurse is planning care for a client who is 2 hr postpartum. Which of the following
interventions should the nurse plan to implement during the taking hold phase of postpartum
behavioural adjustment?
Answer: Demonstrate to the client how to perform a newborn bath
Rationale: Demonstrating the client how to perform a newborn bath occurs during the
taking- hold phase. The new mother moves from being passively dependant to taking a
stronger interest in her new role as a mother. She is now focusing on the care her newborn
and acquiring parenting skills. The nurse should provide positive reinforcement during this
phase to give the new mother confidence and promote maternal adjustment.
46. A nurse is developing a plan of care for a client who has preeclampsia and is rec
magnesium sulfate via a IV. Which of the following interventions should the nurse include in
the plan?
Answer: Monitor the FHR continuously
Rationale: The nurse should monitor the fetal heart rate (FHR) continuously because
magnesium sulfate can cross the placenta and affect the fetus, potentially leading to fetal
distress or altered heart rate patterns. Continuous FHR monitoring helps in promptly
detecting and addressing any adverse effects on the fetus during magnesium sulfate therapy.
47. A nurse is caring for a newborn who is undergoing phototherapy to treat
hyperbilirubinemia. Which of the following actions should the nurse take?
Answer: Cover the newborn's eye's while under the phototherapy light
Rationale: Applying an opaque eye mask prevents damage to the newborn's retinas and
corneas from the phototherapy light.
48. A nurse caring for a client who is at 15 weeks of gestation, is Rh neg and has just had an
amniocentesis. Which of the following interventions is the nurse's priority following the
procedure?
Answer: Monitor the FHR
Rationale: The greatest risk to this client and her fetus is fetal death. Therefore, the priority
nursing interventions is to monitor the FHR following an amniocentesis
49. A nurse is planning care for a client who is at 24 weeks of gestation and reports daily mild
headaches. Which of the following instructions should the nurse include in the plan of care?
Answer: Recommend that the client perform conscious relaxation techniques daily
Rationale: The nurse should include conscious relaxation techniques in the plan of care as a
way to relieve tension and reduce stress, which can help decrease and eliminate headaches.
Nurse assess for spina bifida first picture
50. A nurse is performing vaginal exam for a client who is in active labor and reports back
pain. The nurse determines that the client is 8 cm dilated, 100% effaced, -2 station, and that
the fetus is in the occiput posterior position. Which of the following actions should the nurse
take?
Answer: Assist the client to the hands and knees position
Rationale: The nurse should assist the client into the hands and knees position during
contractions. This position can help relieve her back pain and it will enable the rotation of the
fetus from the posterior to an anterior occiput position
51. A nurse is teaching a client who is at 24 weeks regarding a 1 hr glucose tolerance test.
Which of the following statements should the nurse include in her teaching?
Answer: A blood glucose of 130-140 is considered a positive screening result
Rationale: The nurse should teach the client that a blood glucose level of 130 to 149 mg/dL
is considered a positive screening. If the client receives a positive result, she will need to
undergo a 3-hr glucose tolerance test to confirm if she has gestational diabetes mellitus (DM)
52. A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which
of the following statements by the client indicates an understanding of the teaching?
Answer: "I will eat foods that appeal to my taste instead of trying to balance my meals"
Rationale: Clients who have hyperemesis gravid rum should eat to taste to avoid nausea.
53. A nurse is providing prenatal teaching to a client who is at 26 weeks . Which of the
following positions should the nurse recommend for the client to increase circulation to the
placenta?
Answer: Side-lying
Rationale: Avoids compression of the vena cava, decreased circulation in the uterus can lead
to having a child who is small for gestational age.
54. 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?
Answer: Cholecystitis, hypertension, migraine headaches
Rationale: These findings in the client's history are contraindications to oral contraceptives
due to potential exacerbation of these conditions or increased risk of complications. Oral
contraceptives can worsen cholecystitis, raise blood pressure in individuals with
hypertension, and increase the frequency or severity of migraine headaches. Therefore,
alternative contraceptive methods should be considered for individuals with these medical
histories.
55. A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia
purpura (ITP). Which of the following findings should the nurse expect?
Answer: Decreased platelet count
Rationale: In idiopathic thrombocytopenic purpura (ITP), the client's immune system attacks
and destroys platelets, leading to a decreased platelet count. This condition can result in
increased bleeding and bruising postpartum.
56. A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a
non-stress test (NST). Which of the following statements should the nurse include in the
teaching?
Answer: "You will be offered orange juice to drink during the test."
Rationale: Drinking orange juice during the test can help stimulate fetal movements due to
the sugar content, which can provide more accurate results for the NST by ensuring the baby
is active.
56. A nurse is providing discharge teaching to the parents of a newborn about using a car seat
properly. Which of the following instructions should the nurse include?
Answer: "Position the car seat rear-facing in the back seat of the vehicle."
Rationale: The safest position for a newborn in a vehicle is in a rear-facing car seat placed in
the back seat, which provides optimal protection for the baby's head, neck, and spine in the
event of a collision.
57. A nurse is providing teaching about non-pharm pain management to a client who is
breast-feeding and has engorgement. The nurse should recommend the application of which
of the following items?
Answer: Cold cabbage leaves
Rationale: The application of fresh, raw cabbage leaves that have been chilled is an effective
nonpharmacological method to relieve the pain associated with engorgement.
58. A nurse is preparing to preform Leopold maneuvers for a client. Identify the sequence the
nurse should follow. (Move the steps into the box on the right, placing them in the selected
order of performance. Use all the steps.)
Answer: The first step the nurse should take when performing Leopold maneuvers is to
palpate the client's fundus to identify the fetal part. Second, the nurse should determine the
location of the fetal back. Third, the nurse should palpate for the fatal part presenting at the
inlet. Finally, the nurse should palpate the cephalic prominence to identify the attitude of the
head.
Rationale: The sequence for Leopold maneuvers is: first, palpate the client's fundus to
identify the fetal part; second, determine the location of the fetal back; third, palpate for the
fetal part presenting at the inlet; and finally, palpate the cephalic prominence to identify the
attitude of the head. This order ensures systematic assessment of fetal position and
presentation for optimal maternal and fetal care.
59. A nurse is preforming a newborn assessment. Which of the following images should the
nurse identify as an indication of spina bifida occulta? (images)
Answer: In a newborn assessment, the nurse should identify the image showing a dimple,
tuft of hair, or skin discoloration over the spinal area as an indication of spina bifida occulta.
These signs suggest an underlying issue with the development of the spinal column, which is
characteristic of spina bifida occulta.
Rationale: The nurse should identify this image as spina bifida occulta. External indications
of this neural tube defect include a dimpled area over the defect and the presence of a
birthmark or hairy patch above the area.
(Images of: mongolian spots, spina bifida manifesta in the form of a myelomeningocele that
is open, and spina bifida manifesta in the form of a myelomeningocele that is closed)
