ATI MATERNAL NEWBORN FINAL EXAM
2022/2023 LATEST UPDATE
1. A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia
rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the
following actions should the nurse take? (correct answers)*check for blood under the client's
buttocks*
The nurse should check for blood under the client's buttock to evaluate the amount of lochia
flow and to check for pooling of blood that would otherwise be missed.
2. A nurse is reinforcing teaching about immunizations with a woman in her first trimester of
pregnancy whose diagnostic testing indicates she does not have an immunity to rubella. The
nurse should recommend that the client receive a measles, mumps, rubella (MMR) vaccine at
which of the following times? (correct answers)*prior to discharge from the hospital AFTER
giving birth*
The nurse should recommend the client receive the MMR vaccine following delivery, so she is
protected from contracting rubella then and during any subsequent pregnancies.
3. A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa.
For which of the following findings should the nurse monitor the client? (correct answers)*a
large amount of bright red vaginal bleeding without pain*
With placenta previa, the placenta implants in the lower part of the uterus, partly or completely
obstructing the cervical os, or outlet to the vagina. Clients who have placenta previa have
sudden, painless vaginal bleeding, typically in the third trimester.
4. A nurse is teaching a new mother about signs of effective breastfeeding of her newborn. Which
of the following information should the nurse include in the teaching? (correct answers)*your
baby can lose 5% of body weight during the first few days of life*
The nurse should instruct the mother that the baby can have a weight loss between 5% and 10%
of their birth weight during the first 3 days of life. Breastfed infants usually regain birth weight
by their second or third week of life.
,5. A nurse in a provider's office is reinforcing teaching about home care with a client who has mild
preeclampsia. Which of the following information should the nurse include in the teaching?
(correct answers)*perform daily fetal movements/kick counts*
The client should count the number of fetal movements felt in one hour, preferably after a meal.
Fetal movements are a reassuring sign of fetal oxygenation. The client should notify the provider
if less than 3 movements per hour are noted, as this warrants further evaluation.
6. A nurse is caring for a newborn immediately following delivery. After assuring a patent airway,
which of the following actions should be the nurse's priority? (correct answers)*dry the
newborn*
Drying the newborn is the priority action the nurse should take. Failure to dry the newborn can
result in cold stress, which poses the greatest risk to the infant's safety. Cold stress increases
oxygen demand and can result in respiratory distress and hypoglycemia.
7. A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft;
fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F),
pulse rate 88./min, respiratory rate 18/min. Which of the following actions should the nurse
perform? (correct answers)*ask the client to empty her bladder*
Whenever the fundus is deviated from the midline, a full bladder should be considered as a
potential cause. A full bladder could result in complications such as uterine atony or infection.
8. A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the
following actions should the nurse perform first? (correct answers)*clear the respiratory tract*
Using the airway, breathing, circulation (ABC) priority-setting framework, the first action the
nurse should take is to open the airway of a newborn who was just delivered.
9. A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8
weeks of gestation. Which of the following findings should the nurse expect? (correct
answers)*pelvic pain*
The client will experience a dull to colicky pain at the beginning, progressing to a sharp, stabbing
pain as the tube stretches.
10. A nurse is caring for several newborn clients. For which of the following findings should the
nurse notify the charge nurse? (correct answers)A blood glucose fingerstick of 40 mg/dL for an
infant who is 1-hr old
, Acrocyanosis in an infant who is 2-hr old
*Jaundice in an infant who is 4-hr old*
A hematocrit of 60% in an infant who is 8-hr old
*Rationale*
Jaundice occurring within the first 24 hr of life is related to some type of hemolytic pathology and
requires notifying the charge nurse immediately
11. A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn
intensive care unit (NICU) to await surgery. Which of the following nursing goals is priority in the
care of this infant? (correct answers)*maintain integrity of the sac*
The greatest risk to this client is injury from damage to the exposed spinal cord and fluid filled
sac; therefore, the priority intervention is to maintain the integrity of the sac.
12. A nurse is assisting with the care of a client who is at 32 weeks of gestation and in labor. The
client asks the nurse, "Will my baby be okay?" Which of the following responses should the
nurse make? (correct answers)*you must be feeling very scared*
This response illustrates the therapeutic communication technique of restatement. The nurse
shows empathy for the client by focusing on the client's feelings and recognizing that the client
is scared about the safety of her newborn. This open-ended statement encourages further
communication by the client.
13. A nurse is caring for a client who wants to know if it is possible to have a vaginal birth after a
cesarean birth (VBAC). Which of the following statements by the nurse is appropriate? (correct
answers)*the primary consideration is what type of incision you had*
A transverse incision (also known as a horizontal incision) cuts across the lower, thinner part of
the uterus. It is used during most cesarean births and makes a VBAC possible. A vertical incision
cuts up and down through the uterine muscles that strongly contract during labor and might
cause uterine rupture during a VBAC.
, 14. A nurse is working with an assistive personnel (AP) who is pregnant. The nurse is unsure of the
AP's immune status. Which of the following clients should the nurse safely assign to the AP?
(correct answers)A preschool-age child who has varicella.
*A toddler who has impetigo*
A school-age child who has rubella.
A school-age child who has fifth disease with aplastic crisis.
*Rationale*
Impetigo contagiosa has minimal systemic effects. Therefore, it should be safe for the nurse to
assign the AP care of this client.
15. A nurse is reinforcing teaching with a client about checking her basal temperature to identify
when ovulation occurs. The nurse should instruct the client to check her temperature at which
of the following times? (correct answers)*every morning before arising*
The nurse should instruct the client to measure her temperature every morning throughout her
menstrual cycle, upon waking, before getting out of bed. Activity or movement can raise body
temperature slightly and provide inaccurate results. The client should use a special thermometer
that is accurate to the tenth of a degree.
16. A nurse is reinforcing teaching with a client who is in labor about why epidural anesthesia is not
initiated until a good labor pattern has been established. Which of the following explanations
should the nurse include? (correct answers)*given too soon, epidural anesthesia can prolong
labor*
17. Progress in labor slows when clients are given anesthesia before the active phase of labor. The
medication depresses the central nervous system, thus it will take longer for the cervix to dilate
and efface.
18. A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about
her newborn's hydration. Which of the following nursing observations is appropriate to use in
2022/2023 LATEST UPDATE
1. A nurse is caring for a client who is 4 hr postpartum. The nurse finds a small amount of lochia
rubra on the client's perineal pad. The fundus is midline and firm at the umbilicus. Which of the
following actions should the nurse take? (correct answers)*check for blood under the client's
buttocks*
The nurse should check for blood under the client's buttock to evaluate the amount of lochia
flow and to check for pooling of blood that would otherwise be missed.
2. A nurse is reinforcing teaching about immunizations with a woman in her first trimester of
pregnancy whose diagnostic testing indicates she does not have an immunity to rubella. The
nurse should recommend that the client receive a measles, mumps, rubella (MMR) vaccine at
which of the following times? (correct answers)*prior to discharge from the hospital AFTER
giving birth*
The nurse should recommend the client receive the MMR vaccine following delivery, so she is
protected from contracting rubella then and during any subsequent pregnancies.
3. A nurse is caring for a client who is at 36 weeks of gestation and has suspected placenta previa.
For which of the following findings should the nurse monitor the client? (correct answers)*a
large amount of bright red vaginal bleeding without pain*
With placenta previa, the placenta implants in the lower part of the uterus, partly or completely
obstructing the cervical os, or outlet to the vagina. Clients who have placenta previa have
sudden, painless vaginal bleeding, typically in the third trimester.
4. A nurse is teaching a new mother about signs of effective breastfeeding of her newborn. Which
of the following information should the nurse include in the teaching? (correct answers)*your
baby can lose 5% of body weight during the first few days of life*
The nurse should instruct the mother that the baby can have a weight loss between 5% and 10%
of their birth weight during the first 3 days of life. Breastfed infants usually regain birth weight
by their second or third week of life.
,5. A nurse in a provider's office is reinforcing teaching about home care with a client who has mild
preeclampsia. Which of the following information should the nurse include in the teaching?
(correct answers)*perform daily fetal movements/kick counts*
The client should count the number of fetal movements felt in one hour, preferably after a meal.
Fetal movements are a reassuring sign of fetal oxygenation. The client should notify the provider
if less than 3 movements per hour are noted, as this warrants further evaluation.
6. A nurse is caring for a newborn immediately following delivery. After assuring a patent airway,
which of the following actions should be the nurse's priority? (correct answers)*dry the
newborn*
Drying the newborn is the priority action the nurse should take. Failure to dry the newborn can
result in cold stress, which poses the greatest risk to the infant's safety. Cold stress increases
oxygen demand and can result in respiratory distress and hypoglycemia.
7. A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft;
fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7° C (100° F),
pulse rate 88./min, respiratory rate 18/min. Which of the following actions should the nurse
perform? (correct answers)*ask the client to empty her bladder*
Whenever the fundus is deviated from the midline, a full bladder should be considered as a
potential cause. A full bladder could result in complications such as uterine atony or infection.
8. A nurse is assisting with the care of a newborn following a vaginal delivery. Which of the
following actions should the nurse perform first? (correct answers)*clear the respiratory tract*
Using the airway, breathing, circulation (ABC) priority-setting framework, the first action the
nurse should take is to open the airway of a newborn who was just delivered.
9. A nurse is caring for a client in the prenatal clinic who has a possible ectopic pregnancy at 8
weeks of gestation. Which of the following findings should the nurse expect? (correct
answers)*pelvic pain*
The client will experience a dull to colicky pain at the beginning, progressing to a sharp, stabbing
pain as the tube stretches.
10. A nurse is caring for several newborn clients. For which of the following findings should the
nurse notify the charge nurse? (correct answers)A blood glucose fingerstick of 40 mg/dL for an
infant who is 1-hr old
, Acrocyanosis in an infant who is 2-hr old
*Jaundice in an infant who is 4-hr old*
A hematocrit of 60% in an infant who is 8-hr old
*Rationale*
Jaundice occurring within the first 24 hr of life is related to some type of hemolytic pathology and
requires notifying the charge nurse immediately
11. A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn
intensive care unit (NICU) to await surgery. Which of the following nursing goals is priority in the
care of this infant? (correct answers)*maintain integrity of the sac*
The greatest risk to this client is injury from damage to the exposed spinal cord and fluid filled
sac; therefore, the priority intervention is to maintain the integrity of the sac.
12. A nurse is assisting with the care of a client who is at 32 weeks of gestation and in labor. The
client asks the nurse, "Will my baby be okay?" Which of the following responses should the
nurse make? (correct answers)*you must be feeling very scared*
This response illustrates the therapeutic communication technique of restatement. The nurse
shows empathy for the client by focusing on the client's feelings and recognizing that the client
is scared about the safety of her newborn. This open-ended statement encourages further
communication by the client.
13. A nurse is caring for a client who wants to know if it is possible to have a vaginal birth after a
cesarean birth (VBAC). Which of the following statements by the nurse is appropriate? (correct
answers)*the primary consideration is what type of incision you had*
A transverse incision (also known as a horizontal incision) cuts across the lower, thinner part of
the uterus. It is used during most cesarean births and makes a VBAC possible. A vertical incision
cuts up and down through the uterine muscles that strongly contract during labor and might
cause uterine rupture during a VBAC.
, 14. A nurse is working with an assistive personnel (AP) who is pregnant. The nurse is unsure of the
AP's immune status. Which of the following clients should the nurse safely assign to the AP?
(correct answers)A preschool-age child who has varicella.
*A toddler who has impetigo*
A school-age child who has rubella.
A school-age child who has fifth disease with aplastic crisis.
*Rationale*
Impetigo contagiosa has minimal systemic effects. Therefore, it should be safe for the nurse to
assign the AP care of this client.
15. A nurse is reinforcing teaching with a client about checking her basal temperature to identify
when ovulation occurs. The nurse should instruct the client to check her temperature at which
of the following times? (correct answers)*every morning before arising*
The nurse should instruct the client to measure her temperature every morning throughout her
menstrual cycle, upon waking, before getting out of bed. Activity or movement can raise body
temperature slightly and provide inaccurate results. The client should use a special thermometer
that is accurate to the tenth of a degree.
16. A nurse is reinforcing teaching with a client who is in labor about why epidural anesthesia is not
initiated until a good labor pattern has been established. Which of the following explanations
should the nurse include? (correct answers)*given too soon, epidural anesthesia can prolong
labor*
17. Progress in labor slows when clients are given anesthesia before the active phase of labor. The
medication depresses the central nervous system, thus it will take longer for the cervix to dilate
and efface.
18. A nurse is caring for a client who is breastfeeding and tells the nurse that she is concerned about
her newborn's hydration. Which of the following nursing observations is appropriate to use in
