ATI RN MATERNAL PRACTICE PROCTORED 2023 RETAKE EXAM
WITH NGN WUESTIONS AND ANSWERS WITH RATIONALES
(VERIFIED REVISED)
A nurse is caring for a client who is to receive 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
Late decelerations are indicative of uteroplacental insufficiency. Therefore, this is a
contraindication for the administration of oxytocin and should be reported to the provider.
A nurse is caring for a client who is 32 weeks of gestation and has gonorrhea. The nurse should
identify that the client is at an increased risk for which of the following complications?
Answer: Premature rupture of membranes
The nurse should identify that a client who is pregnant and has gonorrhea is at an increased risk
for premature rupture of membranes, chorioamnionitis, preterm birth, neonatal sepsis, and
intrauterine growth restriction.
A nurse is performing a vaginal examination on a client who is in labor and observes the
umbilical cord protruding from the vagina. After calling for assistance, which of the following
actions should the nurse take?
Answer: Insert two gloved fingers into the vagina and apply upward pressure to the presenting
part.
The nurse should quickly apply gloves and insert two fingers into the vagina toward the cervix,
exerting upward pressure onto the presenting part to relieve umbilical cord compression and
increase oxygenation to the fetus.
A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a nonstress
test. Which of the following instructions should the nurse include?
Answer: "You should press the handheld button when you feel your baby move."
The nurse should instruct the client to press the handheld button when the fetus moves. This
action will mark the fetal monitor tracing with the client's reports of fetal movement. This will
assist in the interpretation of the nonstress test to determine if it is reactive or nonreactive.
A nurse in a provider's office is reviewing the medical record of a client who is in the first
trimester of pregnancy. Which of the following findings should the nurse identify as a risk factor
for the development of preeclampsia?
Answer: Pregestational diabetes mellitus
Pregestational diabetes mellitus increases a client's risk for the development of preeclampsia.
Other risk factors include preexisting hypertension, renal disease, systemic lupus erythematosus,
and rheumatoid arthritis.
A nurse is assessing a client who is at 38 weeks of 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 (4.8 lb)
A weight gain of 2.2 kg (4.8 lb) in a week is above the expected reference range and could
indicate complications. Therefore, this finding should be reported to the provider.
A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which
of the following manifestations should the nurse expect? (SATA)
Answer: • Acrocyanosis
• Positive Babinski reflex
• Two umbilical arteries visible
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?
Answer: Perform Leopold maneuvers.
The nurse should perform Leopold maneuvers to assess the position of the fetus to best
determine the optimal placement for the external fetal monitoring transducer.
A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should
the nurse see first?
Answer: A client who is at 11 weeks of gestation and reports abdominal cramping
When using the urgent vs nonurgent approach to client care, the nurse should determine that the
priority finding is a client who is at 11 weeks of gestation and reports abdominal cramping.
Abdominal cramping can indicate an ectopic pregnancy or manifestations of spontaneous
abortion. The nurse should request that the provider see this client first.
A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for
magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the
following adverse effects?
Answer: Respiratory rate 10/min
The nurse should report a respiratory rate of less than 12/min to the provider, because this is a
manifestation of magnesium toxicity. The nurse should ensure that the antidote, calcium
gluconate, is readily available.
A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the
nurse report to the provider?
Answer: Substernal retractions
The nurse should identify that substernal retractions, apnea, grunting, nasal flaring, and
tachypnea are manifestations of neonatal infection or respiratory distress in the newborn. The
nurse should report these findings to the provider for immediate intervention.
A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress
test. The nurse should plan to prepare the client for which of the following diagnostic tests?
Answer: Biophysical profile
A positive contraction stress test indicates that further evaluation of the fetus is necessary. A
biophysical profile will provide further evaluation with a real-time ultrasound.
A nurse is developing a plan of care for a client who has preeclampsia and is receiving
magnesium sulfate via a continuous IV infusion. Which of the following interventions should the
nurse include in the plan?
Answer: Monitor the FHR continuously.
Magnesium sulfate, which is used to prevent seizures in clients who have preeclampsia, is a
high-alert medication that requires close monitoring. The FHR and uterine contractions should be
monitored continuously while the client is receiving magnesium sulfate.
A nurse is caring for a client who is receiving heparin via a continuous IV infusion for
thrombophlebitis in her left calf. Which of the following actions should the nurse take?
Answer: Maintain the client on bed rest.
The client should remain on bed rest to decrease the risk of dislodging the clot, which could
cause a pulmonary embolism. Elevation of the affected leg is recommended.
A nurse in an antepartum clinic is providing care for a client who is at weeks of gestation. Upon
reviewing the client's medical record, which of the following findings should the nurse report to
the provider?
Answer: Fundal height measurement
A fundal height measurement of 30 cm should be reported to the provider. Fundal height should
be measured in centimeters and is the same as the number of gestational weeks plus or minus 2
weeks from 18 to 32 weeks gestation. Therefore, the nurse should report this finding to the
provider.
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.
The greatest risk to the client and her 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 is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of
the following instructions should the nurse include?
Answer: "You can still become pregnant if you are breastfeeding."
The nurse should instruct the client that breastfeeding does not prevent ovulation. Therefore, the
client can become pregnant. The nurse should discuss contraception that is safe to use while
breastfeeding.
A nurse is assessing a client who has gestational diabetes mellitus and is experiencing
hyperglycemia. Which of the following findings should the nurse expect?
Answer: Reports increased urinary output
Increased urinary output, nausea and vomiting, reports of thirst, abdominal pain, constipation,
drowsiness, and headaches are manifestations of hyperglycemia. Other manifestations include
weak rapid pulse, fruity breath odor, urine positive for sugar and acetone, and a blood glucose
level greater than 200 mg/dL.
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 temperature of 37.7° C (99.9° F)
An axillary temperature greater than 37.5° C (99.5° F) is above the expected reference range for
a newborn and can be an indication of sepsis. Therefore, the nurse should report this finding to
the provider.
A nurse is caring for a client who is at 15 weeks of gestation, is Rh-negative, and has just had an
amniocentesis. Which of the following interventions is the nurse's priority following the
procedure?
Answer: Monitor the FHR.
The greatest risk to this client and her fetus is fetal death. Therefore, the priority nursing
intervention is to monitor the FHR following an amniocentesis.
A nurse is caring for a patient who has hyperemesis gravidarum and is receiving IV fluid
replacement. Which findings should the nurse report to HCP?
Answer: BUN 25 mg/dL
The nurse should report an elevated BUN to the provider since it can indicate dehydration.
A nurse is caring for a client who's 26 weeks gestation and has epilepsy. The nurse enters the
room and observes the patient having a seizure. After turning patient's head to one side, which
actions should the nurse take immediately after the seizure?
Answer: Administer oxygen via a nonrebreather mask.
When using the airway, breathing, and circulation approach to client care, the nurse should place
the priority on administering oxygen to the client via a nonrebreather mask at 10 L/min to ensure
adequate oxygenation to the fetus.
A nurse is assessing a late preterm newborn. Which of the following manifestations is an
indication of hypoglycemia?
Answer: Respiratory distress
Late preterm newborns are at an increased risk for hypoglycemia due to decreased glycogen
stores and immature insulin secretion. Respiratory distress is a manifestation of hypoglycemia.
Other manifestations of hypoglycemia include an abnormal cry, jitteriness, lethargy, poor
feeding, apnea, and seizures.
A nurse is providing teaching about nonpharmacological pain management to a client who is
breastfeeding and has engorgement. The nurse should recommend the application of which of the
following items?
Answer: Cold cabbage leaves
The application of fresh, raw cabbage leaves that have been chilled is an effective
nonpharmacological method to relieve the pain associated with engorgement. The nurse should
instruct the client to place the cabbage leaves on the breasts for 15 to 20 min, repeating the
application for two to three sessions as needed. More frequent applications could decrease the
client's milk supply.
A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental
abruption. Which of the following laboratory tests should the nurse expect the provider to
prescribe?
Answer: Kleihauer- Betke test
The nurse should expect the provider to prescribe a Kleihauer-Betke test for a client who has
suspected placental abruption to determine if fetal blood is in maternal circulation. This test is
useful to determine if Rho-(D) immune globulin therapy should be administered to a client who
is Rhnegative.
A nurse is providing teaching to patient who gave birth 2 hrs ago about facility policy for
newborn safety. Which patient statements indicates an understanding of teaching?
Answer: "The person who comes to take my baby's pictures will be wearing a photo
identification badge."
All personnel working on the unit should be wearing a photo identification badge. The nurse
should instruct the parent to never allow anyone who is not wearing an identification badge to
come in contact with the newborn.
A nurse is caring for prenatal patient with parvovirus B19 (5th disease). Which of the following
actions should the nurse take?
Answer: Schedule an ultrasound examination.
The nurse should schedule serial ultrasound examinations to monitor the fetus during the
pregnancy to detect the possible development of fetal hydrops. Also, the virus can cause
miscarriage, intrauterine growth restriction, fetal anemia, or stillbirth.
A nurse is caring for patient who is at 35 weeks gestation and is undergoing a nonstress test that
reveals variable deceleration in FHR. Which of the following actions should the nurse take?
Answer: Have the client change position.
Having the client change position is an appropriate intervention for a variable deceleration to
relieve umbilical cord compression.
A nurse is developing a plan of care for a newborn who is to undergo phototherapy for
hyperbilirubinemia. Which of the following actions should the nurse include in plan?
Answer: Remove all clothing from the newborn except the diaper.
The nurse should remove all the newborn's clothing except the diaper while under phototherapy.
Maximum skin exposure to the ultraviolet light is needed to break down the excess bilirubin.
A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy.
Which statements by patient indicates an understanding of teaching?
Answer: "I should take 600 micrograms of folic acid each day."
A client who is pregnant should increase folic acid intake to 600 mcg daily. Folic acid assists
with preventing neural tube birth defects.
A nurse is assessing a client who's receiving morphine via IV bolus for pain following c-section.
Nurse notes RR of 8/min. Which meds should the nurse administer?
Answer: Naloxone
Morphine is a common opioid analgesic used for postoperative pain management that can cause
central nervous system depression and can cause respiratory depression. The nurse should
administer naloxone, an opioid antagonist, to reverse the opioid-induced respiratory depression
in the client.
A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of
the following findings should the nurse expect?
Answer: FHR 152/min
The expected range for the FHR is 110/min to 160/min. The FHR is higher earlier in gestation
with an average of approximately 160/min at 20 weeks of gestation. Therefore, this is an
expected finding by the nurse.
A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the
following manifestations should the nurse expect?
Answer: Vaginal pressure
The nurse should expect a client who has a vaginal hematoma to report pressure in the vagina
due to the blood that leaked into the tissues.
A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of
the following findings should the nurse report to the provider?
Answer: Report of decreased fetal movement
The nurse should identify that a client who reports decreased fetal movement could be
experiencing a complication related to fetal well-being. A decrease in fetal movement can
indicate fetal distress.
A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new
prescription for misoprostol. Which of the following instructions should the nurse include in the
teaching?
Answer: "I can administer oxytocin 4 hours after the insertion of the medication."
The nurse can administer oxytocin no sooner than 4 hr after the last dose of misoprostol.
Oxytocin can be administered following misoprostol for clients who have cervical ripening and
have not begun labor.
A nurse is caring for a client who is at 22 weeks of gestations and is HIV positive. Which of the
following actions should the nurse take?
Answer: Report the client's condition to the local health department.
The nurse should report the condition to the local health department. HIV is one of the conditions
on the list of Nationally Notifiable Infectious Conditions that is required to be reported.
A nurse is providing teaching for a client who has a new prescription for combined oral
contraceptives. Which of the following findings should the nurse include as an adverse effect of
this medication?
Answer: Depression
The nurse should instruct the client that depression is a common adverse effect of combined oral
contraceptives. Other common adverse effects of the medication include amenorrhea, weight
gain, headache, nausea, breakthrough bleeding, and breast tenderness.
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 mother's chest.
Placing the newborn skin to skin on the mother's chest is an effective technique to significantly
decrease the newborn's pain level and anxiety. The nurse should implement this technique
before, during, and after the procedure.
A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an
amniocentesis. For which of the following reasons should the nurse prepare the client for an
ultrasound?
Answer: To locate a pocket of fluid
An ultrasound is done to locate a pocket of amniotic fluid and the placenta prior to an
amniocentesis. This decreases the risk of injury to the fetus.
A nurse is providing teaching to a client about physiological changes that occur during
pregnancy. The client is at 10 weeks gestation and has BMI WDL. Which statements indicates an
understanding of teaching?
Answer: "I will likely need to use alternative positions for sexual intercourse."
The weight gain of pregnancy will likely require alternative positions for sexual intercourse. This
client statement indicates that she understands the nurse's teaching about the physiological
changes that occur during pregnancy.
A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord.
Which of the following findings should the nurse expect?
Answer: Petechiae over the head
Nuchal cord, or the umbilical cord being wrapped tightly around the neck, can cause bruising
and petechiae over the face, head, and neck.
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?
Answer: Abruptio placenta
Cocaine use increases the risk for vasoconstriction and possible abruptio placenta.
A nurse is providing education about family bonding to parent who recently adopted a newborn.
The nurse should make which of the following suggestions to aid the family's 7-year-old child in
accepting the new family member?
Answer: Obtain a gift from the newborn to present to the sibling.
Presenting a gift from the newborn to the sibling is a strategy to facilitate a school-age sibling's
acceptance of a new family member. This ensures that the sibling does not feel left out and that
they understand their role in the family.
A nurse is assessing a client who received carbopost for postpartum hemorrhage. Which of the
following findings is an adverse effect of this medication?
Answer: Hypertension
The nurse should recognize that carboprost is a vasoconstrictor that can cause hypertension.
A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should
the nurse report to the provider?
Answer: Jaundice
Jaundice occurring within the first 24 hr of birth is associated with ABO incompatibility,
hemolysis, or Rh- isoimmunization. The nurse should report this manifestation to the provider.
A nurse is observing a new parent caring for her crying newborn who is bottle feeding. Which of
the following actions by the parent should the nurse recognize as a positive parenting behavior?
Answer: Lays the newborn across her lap and gently sways
This is a correct technique for quieting a newborn. This tactile stimulation promotes a sense of
security for the newborn.
Nurse prepares to adm. mag sulfate 2 g/hr IV to patient in preterm labor. Available is 20 g mag
sulfate in 500 ml of dextrose 5% in H2O (D5W). Nurse should set IV infusion pump to adm how
many ml/hr?
Answer: 50
A nurse is transporting a newborn back to the parent's room following a procedure. Which of the
following actions should the nurse take?
Answer: Verify that the parent's identification band matches the newborn's identification band.
The nurse should verify the newborn's identity every time the newborn is returned to the parents.
The nurse should match the information on the parent's identification band to the information on
the newborn's identification band.
A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings
should the nurse report to the provider?
Answer: Report of visual disturbances
Visual disturbances such as blurred vision are a potential prenatal complication associated with
hypertension. The nurse should report this finding to the provider so that additional fetal and
maternal evaluation can be performed.
A nurse is caring for patient who's experiencing preeclampsia and has a new prescription for IV
mag sulfate. Which meds should the nurse anticipate administrating if the client develops mag
toxicity?
Answer: Calcium gluconate
The nurse should anticipate administering calcium gluconate if the client develops magnesium
toxicity. Calcium gluconate is the antidote.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard
Score. Which of the following findings should the nurse expect?
Answer: Minimal arm recoil
The nurse should expect a newborn who was born at 26 weeks of gestation to have decreased
muscular tone, or minimal arm recoil.
A nurse is creating a plan of care for a client who is postpartum and adheres to traditional
Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in
the plan of care?
Answer: Protect the client's head and feet from cold air.
Protecting the client's head and feet from cold air should be included in the plan of care because
this is a traditional Hispanic practice during the postpartum period.
A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations
should the nurse expect?
Answer: Blurred vision
The nurse should identify that a client who has severe preeclampsia can have arteriolar
vasospasms and decreased blood flow to the retina which can lead to visual disturbances, such as
blurred vision, double vision, or dark spots in the visual field.
A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn
screening. Which of the following statements should the nurse include in the teaching?
Answer: "Ensure that the newborn has been receiving feedings for 24 hours prior to obtaining
the specimen."
The nurse should ensure that the newborn has been receiving regular feedings for at least 24 hr
prior to testing.
A nurse is demonstrating how to bathe their newborn. Which order should the nurse perform
actions?
Answer: • Wipe the newborn's eyes from the inner canthus outward.
• Wash the newborn's neck by lifting the newborn's chin.
• Cleanse the skin around the newborn's umbilical cord stump.
• Clean the newborn's diaper area.
• Wash the newborn's legs and feet.
• The nurse should demonstrate how to bathe a newborn by using a head to toe, clean to dirty,
approach. Therefore, the nurse should first wipe the newborn's eyes from the inner canthus
outward using plain water. The nurse should then wash the newborn's neck by lifting the
newborn's chin. Next, the nurse should cleanse the skin around the umbilical cord stump
followed by washing the newborn's legs and feet. The last step of the bath should be to clean the
newborn's diaper area.
A nurse is performing a physical assessment of a newborn. Which of the following clinical
findings should the nurse expect? (SATA)
Answer: Heart rate 154/min is correct. The expected reference range for a newborn's heart rate is
from 110/min to 160/min while awake.
Respiratory rate 58/min is correct. The expected reference range for a newborn's respiratory rate
is from 30/min to 60/min.
Weight 2.6 kg (5 lb 12 oz) is correct. The expected reference range for a newborn's weight is
from 2,500 to 4,000 g (5.5 lb to 8.8 lb).
A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The
provider prescribed betamethasone 12 mg IM. Which of the following outcomes should the nurse
expect?
Answer: A reduction in respiratory distress in the newborn
Betamethasone is a glucocorticoid that is given to stimulate fetal lung maturity and prevent
respiratory distress.
A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage.
Which of the following actions is the nurse's priority?
Answer: Massage the client's fundus.
Uterine atony and postpartum hemorrhage indicate that this client is at the greatest risk for
hypovolemic shock. This can compromise the perfusion to the client's vital organs, which can
lead to death. Therefore, the nurse's priority is to massage the client's fundus to minimize blood
loss.
A nurse is reviewing the prenatal laboratory results for a client who is at 12 weeks of gestation
following an initial prenatal visit. Which of the following laboratory findings should the nurse
report to the provider?
Answer: Hemoglobin 10 g/dL
A hemoglobin of 10 g/dL is below the expected reference range of greater than 11 g/dL for a
client who is pregnant. The nurse should report this finding to the provider to obtain a
prescription for ferrous iron supplementation because of anemia.
