ATI RN Maternal Newborn 2024/2025 with NGN (proctored) with
verified answers
1. Question:
A nurse is caring for a postpartum client who delivered via cesarean
section. The nurse observes the client’s incision site for signs of
infection. Which of the following findings would be most concerning to
the nurse?
A. Slight redness around the incision B. Clear drainage from the incision
C. Fever and purulent drainage from the incision D. Mild tenderness at
the incision site
Answer: C. Fever and purulent drainage from the incision
Rationale: Fever and purulent drainage are indicative of an infection at
the incision site, which is concerning and requires immediate
intervention. Mild redness or tenderness and clear drainage are
common in the early postpartum period but should still be monitored
for any changes.
2. Question:
A nurse is teaching a new mother about breastfeeding. Which
statement by the mother indicates the need for further teaching?
A. "I will nurse my baby every 2-3 hours." B. "I should wash my nipples
with soap and water before each feed." C. "It is normal for my breasts
to feel firm after breastfeeding." D. "I should let the baby nurse on each
breast until it’s done."
,Answer: B. "I should wash my nipples with soap and water before
each feed."
Rationale: The use of soap and water can dry out the nipples and cause
irritation. The mother should only rinse with water and avoid harsh
soaps. Frequent nursing and allowing the baby to finish one breast
before offering the other are recommended practices.
3. Question:
A nurse is assessing a newborn who is 1 hour old. Which of the
following findings should be immediately reported to the healthcare
provider?
A. Heart rate of 130 beats per minute B. Respiratory rate of 60 breaths
per minute C. Cyanosis of the hands and feet D. A weight loss of 8% of
birth weight
Answer: D. A weight loss of 8% of birth weight
Rationale: A weight loss of more than 7-10% in the first few days of life
is concerning and should be reported, as it may indicate dehydration or
feeding issues. The other findings (normal heart rate, respiratory rate,
and physiological cyanosis of extremities) are typically expected in the
first few hours of life.
4. Question:
A nurse is caring for a laboring client who is 8 cm dilated, 100% effaced,
and the baby's head is at +1 station. The nurse observes that the client
is having regular contractions every 2-3 minutes. Which of the following
actions should the nurse take first?
, A. Administer IV pain medication B. Assess the fetal heart rate C. Check
the client's blood pressure D. Encourage the client to push
Answer: B. Assess the fetal heart rate
Rationale: The first priority is to assess the fetal heart rate to ensure
fetal well-being, especially during labor. Monitoring the fetal heart rate
is crucial at all stages of labor, particularly during active labor and
delivery.
5. Question:
A postpartum client who is breastfeeding reports sore nipples. Which of
the following actions should the nurse recommend?
A. Applying a heating pad to the breasts after each feeding B. Changing
the baby's position while nursing C. Allowing the baby to nurse only on
one breast per feeding D. Using nipple shields during breastfeeding
Answer: B. Changing the baby's position while nursing
Rationale: Changing the baby’s position during breastfeeding can help
ensure proper latch and reduce nipple soreness. Applying heat, using
nipple shields, or limiting feeding to one breast per session may not
address the root cause of nipple pain.
6. Question:
A nurse is caring for a newborn who is 24 hours old. Which of the
following actions is a priority for the nurse to take?
A. Administer vitamin K injection B. Bathe the baby with warm water C.
Check for moro reflex D. Place the baby in a bassinette
verified answers
1. Question:
A nurse is caring for a postpartum client who delivered via cesarean
section. The nurse observes the client’s incision site for signs of
infection. Which of the following findings would be most concerning to
the nurse?
A. Slight redness around the incision B. Clear drainage from the incision
C. Fever and purulent drainage from the incision D. Mild tenderness at
the incision site
Answer: C. Fever and purulent drainage from the incision
Rationale: Fever and purulent drainage are indicative of an infection at
the incision site, which is concerning and requires immediate
intervention. Mild redness or tenderness and clear drainage are
common in the early postpartum period but should still be monitored
for any changes.
2. Question:
A nurse is teaching a new mother about breastfeeding. Which
statement by the mother indicates the need for further teaching?
A. "I will nurse my baby every 2-3 hours." B. "I should wash my nipples
with soap and water before each feed." C. "It is normal for my breasts
to feel firm after breastfeeding." D. "I should let the baby nurse on each
breast until it’s done."
,Answer: B. "I should wash my nipples with soap and water before
each feed."
Rationale: The use of soap and water can dry out the nipples and cause
irritation. The mother should only rinse with water and avoid harsh
soaps. Frequent nursing and allowing the baby to finish one breast
before offering the other are recommended practices.
3. Question:
A nurse is assessing a newborn who is 1 hour old. Which of the
following findings should be immediately reported to the healthcare
provider?
A. Heart rate of 130 beats per minute B. Respiratory rate of 60 breaths
per minute C. Cyanosis of the hands and feet D. A weight loss of 8% of
birth weight
Answer: D. A weight loss of 8% of birth weight
Rationale: A weight loss of more than 7-10% in the first few days of life
is concerning and should be reported, as it may indicate dehydration or
feeding issues. The other findings (normal heart rate, respiratory rate,
and physiological cyanosis of extremities) are typically expected in the
first few hours of life.
4. Question:
A nurse is caring for a laboring client who is 8 cm dilated, 100% effaced,
and the baby's head is at +1 station. The nurse observes that the client
is having regular contractions every 2-3 minutes. Which of the following
actions should the nurse take first?
, A. Administer IV pain medication B. Assess the fetal heart rate C. Check
the client's blood pressure D. Encourage the client to push
Answer: B. Assess the fetal heart rate
Rationale: The first priority is to assess the fetal heart rate to ensure
fetal well-being, especially during labor. Monitoring the fetal heart rate
is crucial at all stages of labor, particularly during active labor and
delivery.
5. Question:
A postpartum client who is breastfeeding reports sore nipples. Which of
the following actions should the nurse recommend?
A. Applying a heating pad to the breasts after each feeding B. Changing
the baby's position while nursing C. Allowing the baby to nurse only on
one breast per feeding D. Using nipple shields during breastfeeding
Answer: B. Changing the baby's position while nursing
Rationale: Changing the baby’s position during breastfeeding can help
ensure proper latch and reduce nipple soreness. Applying heat, using
nipple shields, or limiting feeding to one breast per session may not
address the root cause of nipple pain.
6. Question:
A nurse is caring for a newborn who is 24 hours old. Which of the
following actions is a priority for the nurse to take?
A. Administer vitamin K injection B. Bathe the baby with warm water C.
Check for moro reflex D. Place the baby in a bassinette
