1
NGN ATI Maternal Newborn Retake
2026/2027 Actual Exam | Actual Exam
Questions with Verified Answers | Pass
Guaranteed - A+ Graded
Preeclampsia
Scenario Part 1 (Recognizing Cues):
A 32-year-old patient at 34 weeks gestation presents to the labor and delivery unit with a blood
pressure of 158/96 mmHg and 2+ proteinuria. She reports a headache and blurred vision. She has
1+ pitting edema in her lower extremities. Fetal heart rate is 140 bpm with moderate variability.
Q1: Which of the following cues are MOST significant for this patient? (Select all that apply)
[ ] A. 34 weeks gestation
[ ] B. Blood pressure 158/96 mmHg [CORRECT]
[ ] C. 2+ proteinuria [CORRECT]
[ ] D. Headache and blurred vision [CORRECT]
[ ] E. 1+ pitting edema
Correct Answer: B, C, D
Rationale: Elevated BP, proteinuria, and neurological symptoms (headache, blurred vision)
indicate severe preeclampsia. Gestational age (A) is relevant but not an acute cue. Edema (E) is
common in pregnancy and not specific to severe preeclampsia.
NGN Domain: Recognizing Cues
Client Need: Physiological Adaptation
Scenario Part 2 (Analyzing Cues):
The patient is diagnosed with severe preeclampsia. The provider orders magnesium sulfate IV.
The nurse assesses deep tendon reflexes and finds them to be 3+ (hyperreflexia). Urine output is
20 mL over the past hour.
Q2: Based on the assessment findings, which of the following conditions is the patient at risk
for?
,2
A. Eclampsia [CORRECT]
B. Placental abruption
C. Gestational diabetes
D. Preterm labor
Correct Answer: A
Rationale: Hyperreflexia and decreased urine output are signs of worsening preeclampsia and
increased risk for eclampsia (seizures). Options B, C, and D are not directly indicated by these
findings.
NGN Domain: Analyzing Cues
Client Need: Physiological Adaptation
Scenario Part 3 (Prioritizing Hypotheses):
The patient is started on magnesium sulfate. The nurse is monitoring for magnesium toxicity.
Q3: Which of the following is the priority nursing diagnosis for this patient?
A. Risk for injury related to potential seizure activity [CORRECT]
B. Impaired gas exchange related to fluid overload
C. Risk for infection related to invasive monitoring
D. Anxiety related to hospitalization
Correct Answer: A
Rationale: Risk for injury from seizure activity is the priority in severe preeclampsia. Options B,
C, and D are important but not the immediate priority.
NGN Domain: Prioritizing Hypotheses
Client Need: Safety and Infection Control
Scenario Part 4 (Generating Solutions):
The patient is receiving magnesium sulfate. The nurse is monitoring for signs of magnesium
toxicity.
Q4: Which of the following are signs of magnesium toxicity? (Select all that apply)
[ ] A. Respiratory rate 10 breaths/min [CORRECT]
[ ] B. Deep tendon reflexes 2+
,3
[ ] C. Urine output 30 mL/hr
[ ] D. Decreased level of consciousness [CORRECT]
[ ] E. Absent deep tendon reflexes [CORRECT]
Correct Answer: A, D, E
Rationale: Magnesium toxicity presents with respiratory depression (<12 breaths/min), decreased
LOC, and absent deep tendon reflexes. Option B (2+ reflexes) is normal. Option C (30 mL/hr) is
adequate.
NGN Domain: Generating Solutions
Client Need: Pharmacological and Parenteral Therapies
Scenario Part 5 (Taking Action):
The nurse notes that the patient's respiratory rate is 10 breaths/min, and deep tendon reflexes are
absent. Magnesium sulfate is infusing at 2 g/hr.
Q5: Which of the following actions should the nurse take FIRST?
A. Administer calcium gluconate
B. Stop the magnesium sulfate infusion [CORRECT]
C. Notify the provider
D. Administer oxygen
Correct Answer: B
Rationale: The first action for magnesium toxicity is to stop the infusion. Option A (calcium
gluconate) is the antidote but is given after stopping the infusion. Option C should follow. Option
D may be needed but not first.
NGN Domain: Taking Action
Client Need: Pharmacological and Parenteral Therapies
Scenario Part 6 (Evaluating Outcomes):
After stopping the magnesium infusion and administering calcium gluconate, the patient's
respiratory rate returns to 14 breaths/min, and reflexes return to 2+.
Q6: Which of the following outcomes indicates that the intervention was effective?
A. Respiratory rate 10 breaths/min
B. Deep tendon reflexes 2+ [CORRECT]
, 4
C. Absent deep tendon reflexes
D. Decreased level of consciousness
Correct Answer: B
Rationale: Return to normal reflexes (2+) indicates resolution of magnesium toxicity. Options A,
C, and D indicate ongoing toxicity.
NGN Domain: Evaluating Outcomes
Client Need: Pharmacological and Parenteral Therapies
UNFOLDING CASE STUDY 2: Postpartum Hemorrhage
Scenario Part 1 (Recognizing Cues):
A patient delivered an 8 lb 6 oz infant 2 hours ago. The nurse assesses the fundus and finds it
boggy and deviated to the right. Lochia is heavy with large clots. Vital signs: BP 90/50 mmHg,
HR 120 bpm, RR 20/min.
Q7: Which of the following cues are MOST significant? (Select all that apply)
[ ] A. Boggy fundus [CORRECT]
[ ] B. Fundus deviated to the right [CORRECT]
[ ] C. Heavy lochia with large clots [CORRECT]
[ ] D. BP 90/50 mmHg [CORRECT]
[ ] E. HR 120 bpm [CORRECT]
Correct Answer: A, B, C, D, E
Rationale: Boggy fundus indicates uterine atony. Deviation suggests a full bladder. Heavy
bleeding with clots, hypotension, and tachycardia indicate hemorrhage. All are significant cues.
NGN Domain: Recognizing Cues
Client Need: Physiological Adaptation
Scenario Part 2 (Analyzing Cues):
The nurse massages the fundus and it becomes firm. The fundus is deviated to the right.
Q8: What is the most likely cause of the fundal deviation?
A. Uterine rupture
B. Full bladder [CORRECT]
NGN ATI Maternal Newborn Retake
2026/2027 Actual Exam | Actual Exam
Questions with Verified Answers | Pass
Guaranteed - A+ Graded
Preeclampsia
Scenario Part 1 (Recognizing Cues):
A 32-year-old patient at 34 weeks gestation presents to the labor and delivery unit with a blood
pressure of 158/96 mmHg and 2+ proteinuria. She reports a headache and blurred vision. She has
1+ pitting edema in her lower extremities. Fetal heart rate is 140 bpm with moderate variability.
Q1: Which of the following cues are MOST significant for this patient? (Select all that apply)
[ ] A. 34 weeks gestation
[ ] B. Blood pressure 158/96 mmHg [CORRECT]
[ ] C. 2+ proteinuria [CORRECT]
[ ] D. Headache and blurred vision [CORRECT]
[ ] E. 1+ pitting edema
Correct Answer: B, C, D
Rationale: Elevated BP, proteinuria, and neurological symptoms (headache, blurred vision)
indicate severe preeclampsia. Gestational age (A) is relevant but not an acute cue. Edema (E) is
common in pregnancy and not specific to severe preeclampsia.
NGN Domain: Recognizing Cues
Client Need: Physiological Adaptation
Scenario Part 2 (Analyzing Cues):
The patient is diagnosed with severe preeclampsia. The provider orders magnesium sulfate IV.
The nurse assesses deep tendon reflexes and finds them to be 3+ (hyperreflexia). Urine output is
20 mL over the past hour.
Q2: Based on the assessment findings, which of the following conditions is the patient at risk
for?
,2
A. Eclampsia [CORRECT]
B. Placental abruption
C. Gestational diabetes
D. Preterm labor
Correct Answer: A
Rationale: Hyperreflexia and decreased urine output are signs of worsening preeclampsia and
increased risk for eclampsia (seizures). Options B, C, and D are not directly indicated by these
findings.
NGN Domain: Analyzing Cues
Client Need: Physiological Adaptation
Scenario Part 3 (Prioritizing Hypotheses):
The patient is started on magnesium sulfate. The nurse is monitoring for magnesium toxicity.
Q3: Which of the following is the priority nursing diagnosis for this patient?
A. Risk for injury related to potential seizure activity [CORRECT]
B. Impaired gas exchange related to fluid overload
C. Risk for infection related to invasive monitoring
D. Anxiety related to hospitalization
Correct Answer: A
Rationale: Risk for injury from seizure activity is the priority in severe preeclampsia. Options B,
C, and D are important but not the immediate priority.
NGN Domain: Prioritizing Hypotheses
Client Need: Safety and Infection Control
Scenario Part 4 (Generating Solutions):
The patient is receiving magnesium sulfate. The nurse is monitoring for signs of magnesium
toxicity.
Q4: Which of the following are signs of magnesium toxicity? (Select all that apply)
[ ] A. Respiratory rate 10 breaths/min [CORRECT]
[ ] B. Deep tendon reflexes 2+
,3
[ ] C. Urine output 30 mL/hr
[ ] D. Decreased level of consciousness [CORRECT]
[ ] E. Absent deep tendon reflexes [CORRECT]
Correct Answer: A, D, E
Rationale: Magnesium toxicity presents with respiratory depression (<12 breaths/min), decreased
LOC, and absent deep tendon reflexes. Option B (2+ reflexes) is normal. Option C (30 mL/hr) is
adequate.
NGN Domain: Generating Solutions
Client Need: Pharmacological and Parenteral Therapies
Scenario Part 5 (Taking Action):
The nurse notes that the patient's respiratory rate is 10 breaths/min, and deep tendon reflexes are
absent. Magnesium sulfate is infusing at 2 g/hr.
Q5: Which of the following actions should the nurse take FIRST?
A. Administer calcium gluconate
B. Stop the magnesium sulfate infusion [CORRECT]
C. Notify the provider
D. Administer oxygen
Correct Answer: B
Rationale: The first action for magnesium toxicity is to stop the infusion. Option A (calcium
gluconate) is the antidote but is given after stopping the infusion. Option C should follow. Option
D may be needed but not first.
NGN Domain: Taking Action
Client Need: Pharmacological and Parenteral Therapies
Scenario Part 6 (Evaluating Outcomes):
After stopping the magnesium infusion and administering calcium gluconate, the patient's
respiratory rate returns to 14 breaths/min, and reflexes return to 2+.
Q6: Which of the following outcomes indicates that the intervention was effective?
A. Respiratory rate 10 breaths/min
B. Deep tendon reflexes 2+ [CORRECT]
, 4
C. Absent deep tendon reflexes
D. Decreased level of consciousness
Correct Answer: B
Rationale: Return to normal reflexes (2+) indicates resolution of magnesium toxicity. Options A,
C, and D indicate ongoing toxicity.
NGN Domain: Evaluating Outcomes
Client Need: Pharmacological and Parenteral Therapies
UNFOLDING CASE STUDY 2: Postpartum Hemorrhage
Scenario Part 1 (Recognizing Cues):
A patient delivered an 8 lb 6 oz infant 2 hours ago. The nurse assesses the fundus and finds it
boggy and deviated to the right. Lochia is heavy with large clots. Vital signs: BP 90/50 mmHg,
HR 120 bpm, RR 20/min.
Q7: Which of the following cues are MOST significant? (Select all that apply)
[ ] A. Boggy fundus [CORRECT]
[ ] B. Fundus deviated to the right [CORRECT]
[ ] C. Heavy lochia with large clots [CORRECT]
[ ] D. BP 90/50 mmHg [CORRECT]
[ ] E. HR 120 bpm [CORRECT]
Correct Answer: A, B, C, D, E
Rationale: Boggy fundus indicates uterine atony. Deviation suggests a full bladder. Heavy
bleeding with clots, hypotension, and tachycardia indicate hemorrhage. All are significant cues.
NGN Domain: Recognizing Cues
Client Need: Physiological Adaptation
Scenario Part 2 (Analyzing Cues):
The nurse massages the fundus and it becomes firm. The fundus is deviated to the right.
Q8: What is the most likely cause of the fundal deviation?
A. Uterine rupture
B. Full bladder [CORRECT]
