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ATI Maternal Newborn Practice B
1. A nurse is performing a blood collection via heel stick on a newborn for blood glucose
monitoring. After washing her hands and donning gloves, which of the following actions
should the nurse take next?
Cleanse the site with alcohol and allow it to dry.
The nurse should cleanse the puncture site and allow it to dry to disinfect the skin and avoid
diluting the specimen with alcohol; however, evidence-based practice indicates that the nurse
should take a different action first.
Warm the newborn's heel.
According to evidence-based practice, the nurse should first warm the newborn's heel for 5 to
10 min to dilate the vessels in the area.
Cuddle and comfort the newborn.
The nurse should cuddle and comfort the newborn; however, evidence-based practice
indicates that the nurse should take a different action first.
Apply pressure using a dry gauze square.
After obtaining the heel stick blood specimen, the nurse should apply pressure to the site using
a dry gauze square to stop the bleeding; however, evidence-based practice indicates that the
nurse should take a different action first.
2. A nurse is reinforcing teaching about a nonstress test with a client who is at 33 weeks
of gestation. Which of the following statements should the nurse include?
"You will receive IV fluids throughout the test."
The nurse should instruct the client that a nonstress test is noninvasive and does not require
an IV infusion. A contraction stress test might require an IV infusion for the administration of
oxytocin.
"You will press a button when you feel the baby move."
The nurse should instruct the client that a nonstress test monitors for accelerations in the FHR
with fetal movement. The client will have a handheld button that she will push when she feels
fetal movements.
,"You will need to avoid eating for 4 hours prior to the test."
The nurse should instruct the client to eat and drink as usual prior to the test. A nonstress test
is noninvasive and does not require fasting.
"You will be prompted to massage your nipples for the test."
The nurse should instruct the client that a nonstress test monitors for accelerations in the FHR
with fetal movement. A contraction stress test might require the client to perform nipple
stimulation to initiate contractions.
3. A nurse is collecting data from a client who is at 37 weeks of gestation. Which of the
following findings should the nurse report to the provider?
Leukorrhea
The nurse should identify that leukorrhea, or vaginal discharge, is an expected finding during
pregnancy.
Nonpitting ankle edema
The nurse should identify that nonpitting ankle edema is an expected finding during the third
trimester of pregnancy.
Tingling in fingers
The nurse should identify that tingling in fingers is an expected finding during pregnancy due to
traction on the brachial plexus nerves.
Blurred vision
The nurse should identify that blurred vision or double vision are manifestations of gestational
hypertension or preeclampsia. The nurse should report this finding to the provider.
4. A nurse is reviewing the medical record of a client who is at 26 weeks of gestation.
Which of the following findings should the nurse identify as a risk factor for the
development of preeclampsia?
Rheumatoid arthritis
The nurse should identify that connective tissue diseases, such as rheumatoid arthritis and
systemic lupus erythematosus, increase a client's risk for preeclampsia.
,BMI of 24
The nurse should identify that obesity, or a BMI greater than 30, increases a client's risk for
preeclampsia. Other risk factors include multifetal gestation, infection, and chronic
hypertension.
Iron-deficiency anemia
The nurse should identify that iron-deficiency anemia does not increase the client's risk for
preeclampsia. Risk factors include multifetal gestation, infection, and chronic hypertension.
Oligohydramnios
The nurse should identify that oligohydramnios, or less than 300 mL of amniotic fluid, does not
increase the client's risk for preeclampsia. Risk factors include multifetal gestation, infection,
and chronic hypertension.
5. A nurse is reinforcing teaching about car seat safety with the guardian of a newborn.
Which of the following statements by the guardian indicates an understanding of the
teaching?
"I will place the baby's car seat in a rear-facing position until she is 1 year old."
The guardian should position the newborn's car seat rear-facing in the middle of the back seat
until she is 2 years old, or as long as she meets the height and weight restrictions set by the
car seat's manufacturer.
"I will position the retainer clip at the level of the baby's armpits."
The guardian should position the retainer clip at the level of the newborn's axillae and not over
the neck or abdomen.
"I will place the shoulder harness straps in a slot 2 inches above the baby's shoulders."
The guardian should place the shoulder harness straps in the slots at or below the level of the
newborn's shoulders.
"I will position the baby at a 60-degree angle in the car seat."
The guardian should position the newborn in the car seat at a 45° angle to prevent the
newborn's head from falling forward, which can lead to airway obstruction and suffocation.
, 6. A nurse is contributing to the plan of care for a client who has eclampsia. Which of the
following interventions should the nurse identify and plan to include as the priority
immediately following a seizure?
Initiate an IV line with an 18-gauge needle.
The nurse should use an 18-gauge catheter to administer magnesium sulfate to the client;
however, there is another action the nurse should take first.
Insert an indwelling urinary catheter.
The nurse should insert an indwelling urinary catheter to monitor the client's output; however,
there is another action the nurse should take first.
Administer oxygen via facemask at 10 L/min.
The first action the nurse should take when using the airway, breathing, circulation approach to
client care is to administer oxygen via facemask at 10 L/min.
Place blankets on the raised side rails of the bed.
The nurse should raise the side rails of the client's bed and pad the rails with blankets or
pillows to ensure the client's safety; however, there is another action the nurse should take
first.
7. A nurse is reinforcing teaching about breastfeeding with a client who has a 12-hr-old
newborn. Which of the following statements should the nurse identify as an indication
that the client understands the instructions?
"I will wipe the colostrum off my nipple before my baby feeds."
Colostrum contains immunoglobulins, which provide passive immunity to the newborn.
Colostrum also facilitates the newborn's passage of meconium. Therefore, the client should not
remove the colostrum from her nipple prior to breastfeeding.
"I should wake up my baby to feed during the night."
Parents should awaken the newborn to feed every 4 hr at night for the first 24 to 48 hr after
birth. Once the newborn is gaining weight, adequately progressing to demand feedings is safe.
"Since I am breastfeeding, I won't need to give my baby iron supplements until he's a year old."
ATI Maternal Newborn Practice B
1. A nurse is performing a blood collection via heel stick on a newborn for blood glucose
monitoring. After washing her hands and donning gloves, which of the following actions
should the nurse take next?
Cleanse the site with alcohol and allow it to dry.
The nurse should cleanse the puncture site and allow it to dry to disinfect the skin and avoid
diluting the specimen with alcohol; however, evidence-based practice indicates that the nurse
should take a different action first.
Warm the newborn's heel.
According to evidence-based practice, the nurse should first warm the newborn's heel for 5 to
10 min to dilate the vessels in the area.
Cuddle and comfort the newborn.
The nurse should cuddle and comfort the newborn; however, evidence-based practice
indicates that the nurse should take a different action first.
Apply pressure using a dry gauze square.
After obtaining the heel stick blood specimen, the nurse should apply pressure to the site using
a dry gauze square to stop the bleeding; however, evidence-based practice indicates that the
nurse should take a different action first.
2. A nurse is reinforcing teaching about a nonstress test with a client who is at 33 weeks
of gestation. Which of the following statements should the nurse include?
"You will receive IV fluids throughout the test."
The nurse should instruct the client that a nonstress test is noninvasive and does not require
an IV infusion. A contraction stress test might require an IV infusion for the administration of
oxytocin.
"You will press a button when you feel the baby move."
The nurse should instruct the client that a nonstress test monitors for accelerations in the FHR
with fetal movement. The client will have a handheld button that she will push when she feels
fetal movements.
,"You will need to avoid eating for 4 hours prior to the test."
The nurse should instruct the client to eat and drink as usual prior to the test. A nonstress test
is noninvasive and does not require fasting.
"You will be prompted to massage your nipples for the test."
The nurse should instruct the client that a nonstress test monitors for accelerations in the FHR
with fetal movement. A contraction stress test might require the client to perform nipple
stimulation to initiate contractions.
3. A nurse is collecting data from a client who is at 37 weeks of gestation. Which of the
following findings should the nurse report to the provider?
Leukorrhea
The nurse should identify that leukorrhea, or vaginal discharge, is an expected finding during
pregnancy.
Nonpitting ankle edema
The nurse should identify that nonpitting ankle edema is an expected finding during the third
trimester of pregnancy.
Tingling in fingers
The nurse should identify that tingling in fingers is an expected finding during pregnancy due to
traction on the brachial plexus nerves.
Blurred vision
The nurse should identify that blurred vision or double vision are manifestations of gestational
hypertension or preeclampsia. The nurse should report this finding to the provider.
4. A nurse is reviewing the medical record of a client who is at 26 weeks of gestation.
Which of the following findings should the nurse identify as a risk factor for the
development of preeclampsia?
Rheumatoid arthritis
The nurse should identify that connective tissue diseases, such as rheumatoid arthritis and
systemic lupus erythematosus, increase a client's risk for preeclampsia.
,BMI of 24
The nurse should identify that obesity, or a BMI greater than 30, increases a client's risk for
preeclampsia. Other risk factors include multifetal gestation, infection, and chronic
hypertension.
Iron-deficiency anemia
The nurse should identify that iron-deficiency anemia does not increase the client's risk for
preeclampsia. Risk factors include multifetal gestation, infection, and chronic hypertension.
Oligohydramnios
The nurse should identify that oligohydramnios, or less than 300 mL of amniotic fluid, does not
increase the client's risk for preeclampsia. Risk factors include multifetal gestation, infection,
and chronic hypertension.
5. A nurse is reinforcing teaching about car seat safety with the guardian of a newborn.
Which of the following statements by the guardian indicates an understanding of the
teaching?
"I will place the baby's car seat in a rear-facing position until she is 1 year old."
The guardian should position the newborn's car seat rear-facing in the middle of the back seat
until she is 2 years old, or as long as she meets the height and weight restrictions set by the
car seat's manufacturer.
"I will position the retainer clip at the level of the baby's armpits."
The guardian should position the retainer clip at the level of the newborn's axillae and not over
the neck or abdomen.
"I will place the shoulder harness straps in a slot 2 inches above the baby's shoulders."
The guardian should place the shoulder harness straps in the slots at or below the level of the
newborn's shoulders.
"I will position the baby at a 60-degree angle in the car seat."
The guardian should position the newborn in the car seat at a 45° angle to prevent the
newborn's head from falling forward, which can lead to airway obstruction and suffocation.
, 6. A nurse is contributing to the plan of care for a client who has eclampsia. Which of the
following interventions should the nurse identify and plan to include as the priority
immediately following a seizure?
Initiate an IV line with an 18-gauge needle.
The nurse should use an 18-gauge catheter to administer magnesium sulfate to the client;
however, there is another action the nurse should take first.
Insert an indwelling urinary catheter.
The nurse should insert an indwelling urinary catheter to monitor the client's output; however,
there is another action the nurse should take first.
Administer oxygen via facemask at 10 L/min.
The first action the nurse should take when using the airway, breathing, circulation approach to
client care is to administer oxygen via facemask at 10 L/min.
Place blankets on the raised side rails of the bed.
The nurse should raise the side rails of the client's bed and pad the rails with blankets or
pillows to ensure the client's safety; however, there is another action the nurse should take
first.
7. A nurse is reinforcing teaching about breastfeeding with a client who has a 12-hr-old
newborn. Which of the following statements should the nurse identify as an indication
that the client understands the instructions?
"I will wipe the colostrum off my nipple before my baby feeds."
Colostrum contains immunoglobulins, which provide passive immunity to the newborn.
Colostrum also facilitates the newborn's passage of meconium. Therefore, the client should not
remove the colostrum from her nipple prior to breastfeeding.
"I should wake up my baby to feed during the night."
Parents should awaken the newborn to feed every 4 hr at night for the first 24 to 48 hr after
birth. Once the newborn is gaining weight, adequately progressing to demand feedings is safe.
"Since I am breastfeeding, I won't need to give my baby iron supplements until he's a year old."
