ATI PN MATERNAL NEWBORN PROCTORED EXAM 2023 FORM A & B
QUESTIONS AND CORRECT ANSWERS|A+ GRADE
FORM A
A nurse is caring for a client who is at 11 weeks of gestation and reports frequent vomiting.
Which of the following findings should the nurse identify as an indication that the client has
hyperemesis gravidarum?
Answer: • Ketonuria
• Occurs due to the breakdown of fat secondary to malnutrition or starvation
A nurse is collecting data from a client who is at 36 weeks of gestation during a prenatal
examination. Which of the following findings should the nurse report to the provider?
Answer: Blurred vision
i. An indication that the client might have preeclampsia
A nurse is caring for a newborn who has a high-pitched cry and does not respond to consoling
efforts. Which of the following neonatal data collection tools should the nurse expect to
complete?
Answer: • Neonatal abstinence scoring system
• Exhibiting manifestations of opioid withdrawal and should be screened
• Additional manifestations of withdrawal include restlessness, tremors, increased muscle tone,
and an exaggerated Moro reflex
A nurse is caring for a newborn who is receiving phototherapy. Which of the following actions
should the nurse take?
Answer: • Place an opaque mask over the newborn’s eyes
• To prevent damage to the retinas – remove mask for feedings
A nurse is assisting in the care of a newborn immediately following birth. Which of the
following images should the nurse identify as an indication that the newborn was a
myelomeningocele?
Answer: • First picture – exposed spinal cord and fluid filled sac, priority intervention is to
maintain the integrity of the sac
• Myelomeningocele occurs when the neural tube fails to close, and the meninges and spinal cord
herniate
• Defect most often occurs in the lumbar area and may be covered by a thin membranous sac
A nurse is collecting data from a newborn who is 8 hr old. Which of the following findings
should the nurse report to the provider?
Answer: • Apical heart rate of 90/min while crying
• Is below the expected reference range of 110-160 bpm for a newborn; 80-100 bpm while
sleeping; and up to 180 bpm while crying
A nurse is caring for a client 6 hr after a vaginal birth who is going to breastfeed her newborn.
The client reports perineal pain of 6 on a scale from 0-10. The nurse also notes mild perineal
edema and ecchymosis, with a fundus that is 2 cm above the umbilicus with deviation to the
right. Which of the following action is the nurse’s priority?
Answer: • Help the client ambulate to the toilet
• Greatest risk is postpartum hemorrhage from uterine atony; help client to urinate & completely
empty the bladder, which will allow the uterus to contract
A nurse is reinforcing teaching with a client who is at 20 weeks of gestation and has gestational
diabetes mellitus. Which of the following information should the nurse include in the teaching?
Answer: • Consume at least 2000 cal/day
Is about 35 cal/kg/day – will ensure adequate glucose intake and prevent hypoglycemia
A nurse is reinforcing teaching about risk factors for respiratory distress syndrome (RDS) in
newborns with a group of clients who are pregnant. Which of the following risk factors should
the nurse include?
Answer: • Prematurity
• A newborn who is premature has inadequate surfactant production, which can lead to RDS
A nurse is caring for a client who is planning to become pregnant. The client asks the nurse why
folic acid supplements are necessary. The nurse should inform the client that the purpose of the
folic acid supplement is to do which of the following?
Answer: • Prevent certain kinds of birth defects
• Help prevent neural tube defects
A nurse is reinforcing discharge teaching about methods to prevent engorgement during lactation
suppression with a client who is bottle-feeding her newborn. Which of the following statements
should the nurse identify as an indication that the client understands the instructions?
Answer: • “I will apply cold cabbage leaves to my breasts throughout the day.”
• Frequent application of cold leaves to breasts can prevent engorgement
• Should also apply ice packs or cold compresses to breasts, take mild analgesics, and wear a
well-fitting and supportive bra
A nurse is assisting with the care of a client who is at 40 weeks of gestation and is in active labor.
Which of the following findings should the nurse report to the charge nurse?
Answer: • Prolonged deceleration of FHR
• Can be a manifestation of an emergent condition, such as uterine rupture or umbilical cord
prolapse ii. Charge nurse should notify provider about this change
A client requests information about the use of a diaphragm for birth control. Which of the
following statements should the nurse make?
Answer: • “You will need to replace your diaphragm every 2 years.”
A nurse is reinforcing teaching with a client who is at 9 weeks of gestation and reports frequent
episodes of nausea and vomiting. Which of the following instructions should the nurse include?
Answer: • Consume small meals frequently each day
• 5-6 small meals throughout the day – should avoid an empty stomach, as this increases nausea
A nurse on a postpartum unit is assisting in the care of a client who is experiencing hypovolemic
shock. Which of the following actions should the nurse take?
Answer: • Insert an indwelling urinary catheter
• To monitor output closely – decrease kidney perfusion caused by shock can lead to oliguria
A nurse is assisting with planning care for a client who is breastfeeding and has mastitis. Which
of the following recommendations should the nurse include?
Answer: • Instruct the client to apply warm compresses to the affected breast
Will decrease inflammation and edema – will enable more effective emptying of the breast to
prevent milk stasis, which decreases bacterial growth
A nurse is reinforcing teaching about car seat safety with the parent of a newborn. Which of the
following client statements indicates an understanding of the teaching?
Answer: • “If my baby rides in a car with no back seat, the passenger air bag must be turned
off.”
• To prevent potential injuries caused by air bag deployment
A nurse is planning to administer terbutaline to a client who is experiencing preterm labor.
Which of the following routes of administration should the nurse plan to use?
Answer: • Subcutaneous
• Relaxes the smooth muscles and inhibits uterine activity – subcutaneously every 4 hours
A nurse is reviewing the laboratory results of a 4-hour-old newborn. Which of the following
findings should the nurse report to the provider?
Answer: • Platelet count 120,000/mm3
• Is below the expected reference range of 14-24 g/dL for a newborn
A nurse is caring for a client who is at 32 weeks of gestation and has a prescription for
nifedipine. Which of the following outcomes should the nurse expect from this medication?
Answer: • Cessation of uterine contractions
• A calcium channel blocker used to decrease uterine contractions by relaxing the smooth muscle
of the uterus
A nurse is reinforcing teaching about food sources that are high in folate with a group of clients
who are pregnant. Which of the following foods should the nurse recommend to this group as the
best source of folate?
Answer: • ½ cup dried peas
• Provides 127 mcg of folate ii. Should consume 400 mcg of folate/day
A nurse is reinforcing teaching with a client who has asked about continuing routine exercise
during pregnancy. Which of the following responses should the nurse make?
Answer: • “Drink plenty of water after exercising.”
• Drink plenty of water during and after exercising to decrease the risk of dehydration from
diaphoresis
A nurse is caring for a client during the postpartum period. Which of the following findings
should the nurse expect during the first 24 hours following birth?
Answer: • Diuresis
• Results from the loss of excess fluid that is retained during pregnancy
• Discharge of clear, yellow fluid from the breasts
• Called colostrum is present for 3-5 days until the mother’s milk appears and can leak from the
breasts beginning in the third trimester of pregnancy
• Lower abdominal cramping
• Results from the contraction of the uterus as it decreases in size
A nurse in a maternal-newborn unit is caring for a newborn in the nursery. The newborn’s
grandfather asks if he may take the newborn to his daughter’s room. Which of the following
responses should the nurse make?
Answer: • “Let me wash my hands and then I’ll take the baby to his mother.”
• Only facility personnel with appropriate identification badges that indicate that the individual
works specifically in the maternal-newborn unit should transport newborns
A nurse is collecting data from a client who is at 33 weeks of gestation. Which of the following
findings should the nurse identify as an indication of a potential complication of pregnancy?
Answer: • Epigastric pain
• A manifestation of preeclampsia
A nurse is assisting with collecting data from a newborn who was born 2 hours ago and has
respiratory distress. Which of the following findings should the nurse report to the provider?
Answer: • Tachypnea
• Respiratory rate greater than 60/min
• Nasal flaring
• Retractions
• Expiratory grunting
• All are associated with respiratory distress in the newborn
Nurse is reinforcing family planning options with a client who is requesting information about
contraceptives. Which of the following client statements indicates an understanding of the
teaching?
Answer: • “I can use water-soluble lubricant when my partner wears a latex condom.”
• Water-soluble lubricant should be used with male latex condoms, because the use of any other
lubricant can compromise the integrity of the condom 28.
A nurse is assisting with the care of a client who is postpartum and is receiving magnesium
sulfate IV by continuous infusion to treat preeclampsia. Which of the following findings should
the nurse identify as manifestations of magnesium toxicity?
Answer: • Decreased respiratory rate
• Decreased level of consciousness (LOC)
• Double vision
• All manifestations of magnesium sulfate toxicity
A nurse is reinforcing teaching with a client who has preeclampsia and is receiving magnesium
sulfate via continuous IV infusion. Which of the following statements should the nurse include in
the teaching?
Answer: • “Your fluid intake will be limited to no more than 125 milliliters per hour.”
• To prevent fluid overload
A nurse in a prenatal clinic is caring for a group of clients. Which of the following clients should
the nurse recommend the provider see first?
Answer: • A client who is at 37 weeks of gestation and reports a persistent headache
• A persistent headache is a manifestation of preeclampsia
A nurse is caring for a client who is at 30 weeks of gestation. Which of the following findings
should the nurse report to the provider?
Answer: • 2+ urinary protein
• A manifestation of preeclampsia
A nurse is assisting with monitoring a newborn who is 3 days old and has received phototherapy.
Which of the following laboratory values should the nurse recognize as an indication that the
therapy has been effective?
Answer: • Total bilirubin 5 mg/dL
• Used to treat newborns who have hyperbilirubinemia – monitor the newborn’s bilirubin level
before, during, and after phototherapy – expected reference range of 1-12 mg/dL
A nurse is reinforcing teaching with a new parent about the prevention of newborn abduction.
Which of the following statements by the parent indicates an understanding of the teaching?
Answer: • “I will ask the nurse to take my baby back to the nursery if I need to leave my room.”
• Instruct parent not to leave the newborn unattended – if need to leave the room, should call
nurse to transport newborn back to nursery
A nurse is collecting data from a newborn whose mother had gestation diabetes mellitus. Which
of the following findings should the nurse report to the provider?
Answer: • Blood glucose 28 mg/dL
• Is below expected reference range of 40-45 mg/dL for a newborn 35.
A nurse is collecting data from a client who is 32 hours postpartum. Which of the following
findings should the nurse expect?
Answer: Urine output of 3000 mL in 24 hours
i. Expect postpartum diuresis to begin approximately 12 hours after birth – expected urine output
of 3000 mL/24 hours is expected
A nurse is reviewing the laboratory results of a client who is at 32 weeks of gestation. Which of
the following laboratory findings should the nurse report to the provider?
Answer: • Hematocrit 30%
• Is below the expected reference range of greater than 33% for a client who is pregnant ii. Low
Hct is an indication of anemia
A nurse in a prenatal clinic is caring for a client who is at 16 weeks of gestation and has a
positive hepatitis B test result. Which of the following actions should the nurse take?
Answer: • Explain to the client that they will receive the hepatitis B immune globulin
immediately
• To decrease the risk of transmission to the fetus
• Instruct client that all sexual partners and members of the client’s household should see their
providers to begin prophylactic treatment
A nurse is reinforcing teaching about formula feeding a newborn with a group of new parents.
Which of the following instructions should the nurse include?
Answer: • Position the bottle at a 45o angle during feedings
• To allow the newborn to have more control during feedings and prevent the swallowing of air
A nurse is reinforcing home care safety with the guardian of a newborn prior to discharge. Which
of the following statements by the guardian indicates understanding of the teaching?
Answer: • “I should place my baby’s crib away from windows.”
• To prevent drafts or entanglement in blinds or drapery
A nurse is observing a client bathe her 1-day-old newborn. Which of the following actions
should the nurse identify as an indication that the client understands how to bathe the newborn?
Answer: • The client washes the newborn’s hair before unwrapping them
• Helps prevent heat loss
A nurse is reviewing the prenatal record of a client who is at 34 weeks of gestation. Which of the
following results should the nurse identify as a desirable outcome?
Answer: • Reactive non-stress test
• Indicates fetal well-being
A nurse is caring for a newborn who is large for gestational age and is jittery. Which of the
following actions should the nurse take first?
Answer: • Check the newborn’s blood glucose level
A nurse is caring for a client who is experiencing a postpartum hemorrhage. Which of the
following medications should the nurse expect the provider to prescribe?
Answer: • Methylergonovine
• Is an oxytocic medication that causes contraction of the smooth muscle of the uterus, which
assists in decreasing the lochia ii. Should not be administered to clients who have preeclampsia
or hypertension
A nurse is preparing to administer clindamycin 450 mg PO to a client who has endometritis. The
amount available is clindamycin 150 mg/capsule. How many capsules should the nurse
administer?
Answer: • 3 capsules
i. 450/150 = 3
A nurse is caring for a client who is at 20 weeks of gestation and is in the clinic for a routine
prenatal visit. Which of the following findings in the data from the client’s medical record should
the nurse report to the provider?
Answer: • Fundal height
• 20 weeks of gestations should put fundal height at 20 cm plus or minus 2 cm 46.
A nurse on a postpartum unit is assisting with the care of a client who has a hypotonic uterus and
excessive vaginal bleeding. Which of the following actions should the nurse take first?
Answer: • Provide fundal massage for the client
• The greatest risk to this client is postpartum hemorrhage
• Fundal massage to increase uterine muscle tone and express blood clots from the uterus, which
will decrease bleeding
A nurse in an antepartum clinic is reinforcing teaching about how to prevent supine hypotension
with a client who is at 16 weeks of gestation. Which of the following responses by the client
indicates an understanding of the teaching?
Answer: • “I will lie on my left side with my head elevated on a pillow.”
• Uterus compresses the inferior vena cava in the supine position, which decreases blood
pressure and causes dizziness and fainting
A nurse is caring for a client who has received methylergonovine. Which of the following should
the nurse identify and document as an adverse effect of the medication?
Answer: • Hypertension
• An oxytocic agent that stimulates uterine contractions and is used for postpartum hemorrhage
• Can cause nausea, vomiting, cramping, headache, and dizziness
• Report changes in BP due to causing both hypertension AND hypotension
A nurse is reinforcing teaching with a client who is at 20 weeks at gestation and reports having
constipation. Which of the following information should the nurse include?
Answer: • Consume 28 g of fiber per day
• Will help relieve constipation
A nurse is collecting data from a client who is in the second trimester of pregnancy. Which of the
following findings should the nurse report to the provider?
Answer: • Frequent uterine contractions
• Can cause the cervix to open early and subject the client to preterm labor
ATI PN Maternal Newborn 2023 FORM B
A nurse is teaching a client about Rho(D) immunoglobulin (RhoGAM). Which of the following
statements by the client indicated an understanding of the teaching?
A. I will receive this medication if my baby is Rh-negative
B. I will receive this medication at time of delivery
C. I will need a second dose of this medication when my baby is 6 weeks old
D. I will need this medication if I have an amniocentesis- Recommended because of the potential
of fetal RBCs entering the maternal circulation
Answer: D. I will need this medication if I have an amniocentesis- Recommended because of the
potential of fetal RBCs entering the maternal circulation
A nurse is caring for a client who is to receive oxytocin (Pitocin) to augment her labor. Which of
the following contraindicates the initiation of the oxytocin infusion and requires notification of
the provider?
A. Late decelerations- Oxytocin is contraindicated based on late decelerations noted on fetal
assessment findings because they indicate uteroplacental insufficiency.
B. Baseline variability
C. Cessation of uterine dilation
D. Prolonged active phase of labor
Answer: A. Late decelerations- Oxytocin is contraindicated based on late decelerations noted on
fetal assessment findings because they indicate uteroplacental insufficiency.
A nurse on the newborn unit is planning discharge for four clients. Which of the following will
require care beyond that of a standard follow-up visit with the provider after delivery?
A. A newborn being sent home after 22 hr after birth- Screening tests must be repeated if they
were performed before he newborn was 24 hr. old.
B. A newborn at 38 weeks of gestational age
C. A newborn who is bottle feeding
D. Twin newborns with Apgar scores of 8 and 9
Answer: A. A newborn being sent home after 22 hr after birth- Screening tests must be repeated
if they were performed before he newborn was 24 hr. old.
A nurse is assessing a newborn who has a weak cry and is grimacing. The nurse notes the
newborn has a heart rate of 102/min, blueish extremities, and a flaccid muscle tone. Which of the
following reflects the appropriate APGAR score?
A. 4
B. 5
C. 6
D. 7
Answer: B. 5
A nurse is caring for a client who has a history of rheumatic disease, but no physical symptoms
prior to pregnancy. The client begins to experience dyspnea, orthopnea, and pulmonary edema.
Which of the following biological alterations explains this change?
A. Increased maternal weight
B. Increased blood volume- Increase in blood volume during pregnancy increase the workload of
the heart, which causes the symptoms
C. Change in hematocrit levels
D. Change in heart size
Answer: B. Increased blood volume- Increase in blood volume during pregnancy increase the
workload of the heart, which causes the symptoms
A nurse is providing teaching about nonpharmacological pain management for a postpartum
client who is breastfeed and has engorgement. Which of the following methods should the nurse
recommend?
A. Cold cabbage leaves - Application of this is an effective nonpharmacological method to
relieve pain associated with engorgement
B. Modified lanolin cream
C. A breast binder
D. Breast shells
Answer: A. Cold cabbage leaves - Application of this is an effective nonpharmacological
method to relieve pain associated with engorgement
A nurse is providing discharge teaching to a client who is postpartum about resuming sexual
activity. Which of the following instructions should the nurse include in the teaching?
A. You should use a water soluble gel for lubrication- This will prevent discomfort
B. You can resume sexual activity in 10 days
C. Your physical reaction to sexual stimulation ill not be altered
D. You will not ovulate for 3 months after delivery
Answer: A. You should use a water soluble gel for lubrication- This will prevent discomfort
A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which
of the following complications should the nurse assess?
A. Abruptio placenta- Cocaines increases the risk for vasoconstriction and possible abruption
placenta
B. Placenta previa
C. Preeclampsia
D. Maternal bradycardia
Answer: A. Abruptio placenta- Cocaines increases the risk for vasoconstriction and possible
abruption placenta
A nurse is providing dietary teaching with a client who has hyperemesis gravidarum. Which of
the following statements by the client indicates an understanding of the teaching?
A. I should eat to taste instead of trying to balance my meals- Eat to taste to avoid nausea
B. I will avoid having a snack at bedtime
C. I will have 8 oz of hot tea with each meal
D. I should pair my sweets with a starch instead of eating them alone
Answer: A. I should eat to taste instead of trying to balance my meals- Eat to taste to avoid
nausea
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?
A. Warm the heel prior to the puncture
B. Request a prescription for IM analgesic
C. Use a manual lance blade to pierce the skin
D. Swaddle the newborn after the heel puncture- Effective technique to diminish the pain
experience for the newborn.
Answer: D. Swaddle the newborn after the heel puncture- Effective technique to diminish the
pain experience for the newborn.
A nurse is conducting an initial prenatal visit for a client who is at 6 weeks gestation. Which of
the following laboratory tests should be performed?
A. 24 hour urine for protein
B. Group B streptococcus culture
C. 3-hr glucose tolerance
D. Rubella titer- Obtained at the initial prenatal visit to determine immunity to rubella
Answer: D. Rubella titer- Obtained at the initial prenatal visit to determine immunity to rubella
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?
A. Confirm the newborn’s Apgar score
B. Verify the newborn’s identification- Mandatory to continue ongoing identification of the
newborn whenever the newborn is removed from the mother’s direct presence and care.
C. Administer vitamin K IM to the newborn
D. Determine the obstetrical risk factors
Answer: B. Verify the newborn’s identification- Mandatory to continue ongoing identification of
the newborn whenever the newborn is removed from the mother’s direct presence and care.
A nurse is assessing a young adult client in a women’s health clinic who asks for a contraceptive.
The client reports to the nurse a familial history of osteoporosis. Which of the following
contraceptive methods is contraindicated for this client?
A. Combined estrogen-progestin oral contraceptives
B. An intrauterine device
C. Medroxyprogestrone acetate (Depo-provera)-causes a decrease in bone mineral density and
places the client at risk for the development of osteoporosis
D. Norelgestromin/ethinyl estradiol (Ortho Evra)
Answer: C. Medroxyprogestrone acetate (Depo-provera)-causes a decrease in bone mineral
density and places the client at risk for the development of osteoporosis
A nurse is admitting a client to the labor and delivery unit when the client states, “my water just
broke”, which of the following is the priority intervention for the nurse to take?
A. Perform Nitrazine testing
B. Assess the amniotic fluid
C. Check cervical dilation
D. Monitor the fetal heart rate- Rupture of the membranes places the fetus at risk for umbilical
cord prolapse.
Answer: D. Monitor the fetal heart rate- Rupture of the membranes places the fetus at risk for
umbilical cord prolapse.
A nurse in a clinic is caring for a client who is at 32 weeks of gestation. Which of the following
clinical findings should alert the nurse to a potential complication?
A. Fundal height is 34 cm
B. Client reports diarrhea for 3 days- Indicates illness or infection
C. Client reports ankle edema
D. Blood pressure is 130/80
Answer: B. Client reports diarrhea for 3 days- Indicates illness or infection
A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The
fetal monitor shows uterine contractions every 6 min, lasting 20-25 seconds, and an FHR of
150/min. The provider prescribed betamethasone (celestone) 12 mg IM. Which of the following
outcomes should the nurse expect?
A. Decreased uterine contractions
B. An increase in the client’s hemoglobin levels
C. A reduction in respiratory distress in the newborn- Given to stimulate fetal lung maturity and
prevent respiratory distress
D. Increased production of antibodies in the Newborn
Answer: C. A reduction in respiratory distress in the newborn- Given to stimulate fetal lung
maturity and prevent respiratory distress
A nurse is caring for a client newly admitted to the PACU following a cesarean birth. Which of
the following is the priority nursing assessment?
A. Parent-child attachment
B. Amount of postpartum lochia- The greatest risk to the client is bleding. The amount of lochia
can assist the nurse in determining if excessive bleeding is occurring. Assess the client for
postpartum hemorrage.
C. Patency of the IV cathether
D. Quality and quantity of urine output
Answer: B. Amount of postpartum lochia- The greatest risk to the client is bleding. The amount
of lochia can assist the nurse in determining if excessive bleeding is occurring. Assess the client
for postpartum hemorrage.
A nurse is caring for a client whose labor is not progressing due to should sytocia of the infant.
Which of the following actions should the nurse take?
A. Apply fundal pressure
B. Apply suprapubic pressure-can be used to attempt to push the shoulder to go under the
symphysis pubis and thus pass through the birth canals
C. Place the client in the trendelenburg position
D. Place the client in the fowlers position
Answer: B. Apply suprapubic pressure-can be used to attempt to push the shoulder to go under
the symphysis pubis and thus pass through the birth canals
A nurse is preparing to initiate IV oxytocin for a client who is admitted for induction of labor.
Oxytocin 30 units is available in 500 ml. At what rate should the nurse set the infusion pump to
deliver 2mu/min?
A. 30 units/500ml = 0.06units/ml
B. 0.06 units = 60Mu
C. 60mU/1 = 2mU/xmL
D. x = 0.03mL/min 0.03x60 = 1.8mL/hr
Answer: D. x = 0.03mL/min 0.03x60 = 1.8mL/hr
A nurse is planning care for a client who is to undergo a nonstress test. Which of the following
should the nurse include in the plan of care?
A. Maintain the client NPO throughout the procedure
B. Place the client in a supine position
C. Instruct the client to massage the abdomen to stimulate fetal movement
D. Instruct the client to press the provided button each time fetal movement is detected- Fetal
movement may not be evident on the fetal monitor and tracing.
Answer: D. Instruct the client to press the provided button each time fetal movement is detectedFetal movement may not be evident on the fetal monitor and tracing.
A nurse is caring for a client who has been hyperemesis gravidarum and is receiving IV fluid
replacement. Which of the following assessment findings by the nurse should be reported to the
provider?
A. BUN 25 – Elevated BUN can indicate dehydration and should be reported to the provider
B. Serum creatinine 0.8
C. Urine output 280 mL in 8 hr
D. Weight gain of 0.9kg in 24 hr
Answer: A. BUN 25 – Elevated BUN can indicate dehydration and should be reported to the
provider
A nurse is assessing a fetal heart monitor tracing of a client receiving oxytocin at 10
milliunits/min. Uterine contractions are noted every 60 to 90 seconds. After turning the client to
a side-lying position, which of the following actions should the nurse take next?
A. Discontinue the medication infusion- Prolonged contractions reduce the blood flow to the
placenta and result in FHR decelerations; oxytocin should be discontinued.
B. Prepare to administer terbutaline subcutaneously
C. Administer oxygen at 8 to 10 L/min by face mask
D. Increase the maintenance IV fluid rate.
Answer: A. Discontinue the medication infusion- Prolonged contractions reduce the blood flow
to the placenta and result in FHR decelerations; oxytocin should be discontinued.
A nurse is teaching a prenatal class about infant safety. Which of the following statements made
by a parent indicated a need for further teaching?
A. I will set my hot water heater no higher than 130F- To avoid burns to the infant, the hot water
should be set no higher than 49F
B. I will make sure the crib slats are no more than 2 3/8 inches apart
C. I will refrain from using a comforter in the crib
D. I will place the infant carrier on the floor when my baby is inside it
Answer: A. I will set my hot water heater no higher than 130F- To avoid burns to the infant, the
hot water should be set no higher than 49F
A nurse is caring for a client who is in active labor and reports back pain. The nurse performs a
vaginal exam and determines the client is 8cm dilated, 100% effaced, and -2 station. The fetus is
in the occiput posterior position. Which of the following is an appropriate intervention?
A. Perform effleurage during contractions
B. Place the client in lithotomy position
C. Assist the client to the hands and knees position- Helps relieve back pain and help the fetus
rotate
D. Apply a fetal scalp electrode
Answer: C. Assist the client to the hands and knees position- Helps relieve back pain and help
the fetus rotate
A nurse is assessing a client during a weekly prenatal visit that is at 38 weeks of gestation.
Which of the following client findings should the nurse report to the provider?
A. Blood pressure 136/88
B. Report of insomnia
C. Weight gain of 2.2 kg- Above the expected reference range and could indicate complications
D. Report of Braxton- Hicks contractions
Answer: C. Weight gain of 2.2 kg- Above the expected reference range and could indicate
complications
A nurse is caring for a client who is pregnant and has epilepsy. The nurse observes the client
having a seizure. After turning the client’s head to one side, which of the following actions
should the nurse take next?
A. Monitor the fetal heart rate
B. Assess uterine activity
C. Administer oxygen via a non-breather mask
D. Start a bolus of IV fluids
Answer: C. Administer oxygen via a non-breather mask
A nurse is providing discharge instructions to a client who had a vaginal delivery and is
breastfeeding her newborn. Which of the following statements indicates an understanding of the
teaching?
A. I will need to eat an additional 330 calories a day while I’m breastfeeding
B. I will change my perineal pad at least twice a day
C. I will massage my uterus daily for 7 days
D. I will breastfeed my baby every 2 hours
Answer: A. I will need to eat an additional 330 calories a day while I’m breastfeeding
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions
should the nurse take prior to applying an external transducer for fetal monitoring?
A. Assessment of dilation and effacement
B. Leopold maneuvers- helps the nurse assess the position of the fetus to best determine the
optimal placement for the fetal monitoring transducer.
C. Sterile speculum exam
D. Nitrazine test
Answer: B. Leopold maneuvers- helps the nurse assess the position of the fetus to best
determine the optimal placement for the fetal monitoring transducer.
A client who is pregnant presents to a prenatal clinic for her first visit. She tells the nurse that her
last normal menstrual period began Oct 13. Using Nagele’s rule, the nurse should determine the
client’s estimated date of delivery as which of the following?
A. July 6
B. July 13
C. July 20- Add a year, subtract 3 months, add 7 days
D. July 27
Answer: C. July 20- Add a year, subtract 3 months, add 7 days
A nurse is caring for a client undergoing an oxytocin-stimulated contraction test. The nurse notes
three contractions in 10 min with late decelerations occurring with two of the contractions.
Which of the following findings should the nurse report to the provider
A. Reactive
B. Nonreactive
C. Positive- Indicates an adverse reaction by the fetus and should be reported to the provider
D. Negative
Answer: C. Positive- Indicates an adverse reaction by the fetus and should be reported to the
provider
A nurse is providing family planning education to a client who has decided to use a diaphragm.
Which of the following should the nurse include in the plan of care?
A. You should replace the diaphragm every 3 years
B. You should leave the diaphragm in place for at least 6 hours after intercourse
C. You should use an oil based product as a lubricant when inserting the diaphragm
D. You should insert he diaphragm when your bladder is full
Answer: B. You should leave the diaphragm in place for at least 6 hours after intercourse
A nurse is assessing a newborn. Which of the following images indicate an appropriate technique
to assess a newborn?
Answer: A nurse should measure the newborn’s head circumference by positioning the tape
measure above the newborn’s eyebrows and ears to obtain an accurate head circumference.
A nurse is caring for a client who is using jet hydrotherapy during labor. The nurse is aware that
which of the following methods of monitoring the fetal heart rate is contraindicated?
A. A Doppler device
B. A fetoscope
C. A wireless external monitor device
D. An internal electrode
Answer: D. An internal electrode
A nurse is assessing a newborn. Which of the following findings are expected?
A. Slight yellow skin
B. Breast nodule is 6 mm-up to 10 mm can occur
C. Posterior fontanel larger than the anterior fontanel-anterior should be larger
D. Overlapping suture lines
E. Lanugo over the shoulders
Answer: B. Breast nodule is 6 mm-up to 10 mm can occur
D. Overlapping suture lines
E. Lanugo over the shoulders
A nurse is caring for a client who has had a perinatal death. Which of the following statements is
an appropriate response by the nurse?
A. This happens for a reason
B. This must be hard for you-reflects on the feelings of the mother
C. I understand how you feel
D. You’re young and will be able to have other children
Answer: B. This must be hard for you-reflects on the feelings of the mother
A nurse is assessing a newborn who is 24 hr old. Which of the following is an appropriate action
for the nurse to take?
A. Initiate oxygen via nasal canula
B. Administer IV bolus of .9 NS
C. Obtain a blood glucose level
D. Place the newborn in a warmer
Answer: C. Obtain a blood glucose level
A nurse is providing discharge instructions to client whose infant was circumcised using the
clamp the technique. Which of the following responses by the client indicates an understanding
of the teaching?
A. I will apply the diaper loosely if bleeding occurs
B. I will put petroleum jelly around the glans during each diaper change
C. I will wipe off any yellow exudate that forms on the glans
D. I will remove the plastic ring after 7 days
Answer: B. I will put petroleum jelly around the glans during each diaper change
A client in the transitional phase of labor is using breathing techniques to manage her pain.
Which of the following actions by the client should indicate to the nurse that the clients plan of
care should be altered?
A. The client can talk but not walk through contractions
B. The client increases her rate of breathing to relax
C. The client requests to move from the chair to the bed
D. The client reports tingling sensations in her fingers- Indicates the client is hyperventilating.
This causes respiratory alkalosis. Can be reversed by having the client breathe into her cupped
hands or placing a paper bag tightly around her mouth and nose to breath carbon dioxide.
Answer: D. The client reports tingling sensations in her fingers- Indicates the client is
hyperventilating. This causes respiratory alkalosis. Can be reversed by having the client breathe
into her cupped hands or placing a paper bag tightly around her mouth and nose to breath carbon
dioxide.
A nurse on an antepartum unit is reviewing the assessment findings of four clients who are in the
third trimester of pregnancy. Which of the following assessment findings is the highest priority?
A. A client who has gestational diabetes and a fasting blood glucose of 120
B. A client who is reporting epigastric pain- Indicator of hepatic involvement and is a clinical
manifestation of severe preeclampsia. This should be reported immediately. Life-threatening for
the mother and the fetus if left untreated.
C. A client who has a HgB of 10
D. A client who reports urinary frequency and burning upon urination
Answer: B. A client who is reporting epigastric pain- Indicator of hepatic involvement and is a
clinical manifestation of severe preeclampsia. This should be reported immediately. Lifethreatening for the mother and the fetus if left untreated.
A nurse is providing education for a client who is in her third trimester and is scheduled for a
biophysical profile. The nurse should tell the client that which of the following variables is
included in the test?
A. Gestational age
B. L/S ratio
C. Amniotic fluid index
D. Doppler flow analysis
Answer: C. Amniotic fluid index
A nurse is performing a newborn assessment 12 hr after delivery. Which of the following
findings indicate possible neonatal sepsis?
A. Temperature instability
B. Tachypnea
C. Hypertonicity
D. Nasal flaring
E. Irritability
Answer: A. Temperature instability
B. Tachypnea
D. Nasal flaring
E. Irritability
A nurse is caring for a client in labor who is reporting excessive pain. Which of the following
interventions requires the nurse to hold an additional certification or licensure?
A. Acupuncture- A pain control technique that involves the insertion of fine needles into specific
body areas, should be performed by a trained certified therapists.
B. Aromatherapy
C. Effleurage
D. Counterpressure
Answer: A. Acupuncture- A pain control technique that involves the insertion of fine needles
into specific body areas, should be performed by a trained certified therapists.
A nurse is caring for a client who is at 32-weeks of gestation and has gonorrhea. This infection
places the client at increased risk for which of the following during pregnancy?
A. Excessive bleeding
B. Oligohydraminos
C. Premature rupture of membranes
D. Proteinuria
Answer: C. Premature rupture of membranes
A nurse is observing a mother caring for her newborn who is crying. Which of the following
actions by the mother should the nurse recognize as a positive parenting behavior?
A. Lays the newborn across her lap and gently sways
B. Places the newborn in the crib in a prone position
C. Offers the newborn a pacifier dipped in milk
D. Prepares a bottle of milk mixed with rice cereal
Answer: A. Lays the newborn across her lap and gently sways
A nurse is caring for a client who is postpartum and has a history of preeclampsia. Upon
assessment, the nurse observes petechiae and serosanguineous fluid oozing from the IV insertion
site. Which of the following findings should be reported to the provider?
A. HCT 39%
B. Serum albumin 4.5
C. WBC count of 9,000
D. Platelet count of 50,000- Below the reference range and indicates disseminated intravascular
coagulation and should be reported to the provider.
Answer: D. Platelet count of 50,000- Below the reference range and indicates disseminated
intravascular coagulation and should be reported to the provider.
A nurse is providing education about family bonding to parents who recently adopted a newborn.
The nurse should make which of the following suggestions to enable the family’s 7-year-old to
accept the new family member?
A. Allow the sibling to hold the newborn during the bath
B. Make sure the sibling kisses the newborn each night
C. Encourage the sibling to sing to help soothe the newborn- Interaction with the baby helps
make a connection
D. Switch the sibling’s room with the nursery.
Answer: C. Encourage the sibling to sing to help soothe the newborn- Interaction with the baby
helps make a connection
A nurse is caring for a client who is at 38 weeks of gestation and is in labor. The nurse notes late
decelerations on the fetal monitor.
A. Reposition the client on her side
B. Elevate the client’s legs
C. Increase the maintenance IV solution
D. Palpate the uterus to assess for tachysystole and then administer oxygen via face mask at
8L/min
Answer: A. Reposition the client on her side
A nurse is teaching a client who is in preterm labor about terbutaline (brethine). Which of the
following statements by the client indicates an understanding of the teaching?
A. I will get injections of the medication once a day until my labor stops
B. My blood sugar may be low while I’m on this medication
C. I will have blood tests because my potassium might decrease-adverse effect results into
hypokalemia
D. My blood pressure may increase while I’m on the medication
Answer: C. I will have blood tests because my potassium might decrease-adverse effect results
into hypokalemia
A nurse is caring for a client who is in labor with right occiput posterior position. The client is
dilated to 8 cm and reports back pain. Which of the following is an appropriate action for the
nurse to take?
A. Apply sacral counter-pressure-assists in relieving back labor pain related to fetal posterior
position
B. Perform transcutaneous electrical nerve stimulation
C. Initiate slow-paced breathing
D. Assist with biofeedback
Answer: A. Apply sacral counter-pressure-assists in relieving back labor pain related to fetal
posterior position
A nurse is caring for a client who is in premature labor at 32 weeks of gestation and is receiving
magnesium sulfate for tocolytic therapy. The nurse should report which of the following findings
to the provider?
A. Respiratory rate of 12/min
B. Absent deep tendon reflexes- Sign of an adverse reaction to magnesium sulfate and should be
reported to the provider
C. Client report of hot flashes
D. Serum calcium level of 9.5
Answer: B. Absent deep tendon reflexes- Sign of an adverse reaction to magnesium sulfate and
should be reported to the provider
A nurse is performing an admission assessment on a newborn who is large for gestational age.
Which of the following findings indicates a need for further assessment?
A. Heel stick blood glucose of 50 mg/dl
B. Respirations 50/ml
C. Acrocyanosis
D. Jitteriness- Symptom of hypoglycemia for which this infant is at increased risk due to glucose
requirements during the first hour of life
Answer: D. Jitteriness- Symptom of hypoglycemia for which this infant is at increased risk due
to glucose requirements during the first hour of life
A nurse is providing teaching to a client of normal weight who is at 10 weeks of gestation.
Which of the following statements should indicate to the nurse that the client s accepting
expected body image changes related to pregnancy?
A. I will not gain more than 10 to 15 pounds during pregnancy
B. I will use new positions during intercourse
C. I hope I do not get a dark line up my abdomen
D. I will not be able to wear my bikini if I get stretch marks
Answer: B. I will use new positions during intercourse
A nurse is providing education about car seat safety to the parents of a newborn. Which of the
following should be included in the teaching?
A. Secure the car seat harness at the newborns waist
B. Install the car seat facing forward in the car’s back seat
C. Position the newborn in the car seat at a 45 degree angle
D. Obtain approval from hospital staff before purchasing the car seat
Answer: C. Position the newborn in the car seat at a 45 degree angle
A nurse is caring for a client who is 1 day post-vaginal delivery. The nurse determines the
client’s fundus is firm, located 2 fingerbreadths above the umbilicus, and deviated to the left.
Which of the following actions should she take first?
A. Insert an indwelling urinary catheter
B. Notify the provider
C. Assist the client to empty her bladder-greatest risk to this client is subinvolution of the uterus
due to a distended bladder.
D. Encourage the client to ambulate
Answer: C. Assist the client to empty her bladder-greatest risk to this client is subinvolution of
the uterus due to a distended bladder.
A nurse in a provider’s office is assessing a client who is breastfeeding and reports a fever and
body aches. Which of the following additional clinical findings is associated with mastitis?
A. Pink shiny nipples and a visible rash
B. Burning or stinging of the breast during feedings
C. Unilateral breast pain with tenderness
D. Firm areolae with flattened nipples
Answer: C. Unilateral breast pain with tenderness
A nurse is teaching the mother of a newborn about erythromycin ophthalmic ointment 0.5%.
Which of the following should be included in the teaching?
A. We will need you to sign a consent form prior to administration
B. It is required by law that newborns receive this treatment
C. We will administer this medication 3 hr after birth of the newborn
D. We will administer this medication for HPV prophylaxis
Answer: B. It is required by law that newborns receive this treatment
A nurse is caring for a client who has a vaginal hematoma in the immediate postpartum period.
Which of the following assessment findings should the nurse expect to find?
A. Lochia serosa draining from vagina
B. Pressure in the vagina
C. Intermittent vaginal pain
D. Yellow exudate draining from vagina
Answer: B. Pressure in the vagina
A nurse on postpartum unit is caring for a client who has idiopathic thrombocytopenia purpura.
Which of the following assessment findings should the nurse expect to find?
A. Decreased platelet count
B. Increased ESR
C. Decreased megakaryocytes
D. Increased WBC
Answer: A. Decreased platelet count
A nurse is caring for a client who is in labor and has ruptured membranes and one inch of the
umbilical cord protruding into the vagina. After calling for assistance, which of the following is a
priority nursing action?
A. Place a rolled towel beneath one of the client’s hips
B. Apply internal upward pressure to the presenting part-relieves cord compression
C. Administer oxygen at 10L/min
D. Increase the IV infusion rate
Answer: B. Apply internal upward pressure to the presenting part-relieves cord compression
A nurse is caring for a client and her newborn whose culture differs form the nurse’s. Which of
the following indicated a need for intervention by the nurse?
A. Placing of a belly band lightly over the newborn’s navel
B. Delaying feeding until breast milk comes in- If the client waits then the newborn will not
receive any nourishment during the first 1 to 3 days of life.
C. Waiting to name the newborn
D. Using a cradle board to support the newborn
Answer: B. Delaying feeding until breast milk comes in- If the client waits then the newborn
will not receive any nourishment during the first 1 to 3 days of life.
