ATI RN Maternal Newborn Nursing
2025/2026 – Verified Answers &
Rationales | A+ Graded Content
1. A nurse is assessing a client at 12 weeks' gestation. Which of the following fetal
development milestones should the nurse expect?
o A. Lanugo formation
o B. Quickening
o C. Lanugo formation
o D. Viable survival Rationale: Quickening (fetal movement perception) occurs
around 12-16 weeks, marking neuromuscular maturity for fetal oxygenation
stability; early detection reassures placental perfusion per ACOG prenatal
milestones.
2. A nurse is teaching a client about fetal development at 8 weeks' gestation. Which of the
following should the nurse include?
o A. Organogenesis complete
o B. Heartbeat detectable via Doppler
o C. Surfactant production
o D. Bone ossification Rationale: Cardiac activity is audible by transvaginal
Doppler at 8 weeks, confirming embryonic viability and circulatory development
stability for early pregnancy monitoring.
3. A nurse is performing Leopold maneuvers on a client at 36 weeks' gestation. Which of
the following positions indicates a breech presentation?
o A. Soft, irregular mass in fundal region
o B. Hard, round mass in fundal region
o C. Fetal back on right side
o D. Small parts on left side Rationale: Breech presents a hard cephalic pole
fundally, guiding external cephalic version for fetal positioning stability and
vaginal delivery optimization per AWHONN intrapartum care.
4. A nurse is assessing fetal heart rate (FHR) during a non-stress test. Which of the
following findings indicates fetal well-being?
o A. Accelerations with movement
o B. Baseline 140/min with variability
o C. Decelerations late
o D. FHR 90/min Rationale: Moderate variability (6-25 bpm) and baseline 110-
160/min reflect autonomic nervous system maturity, ensuring fetal oxygenation
stability per NICHD FHR interpretation.
5. A nurse is caring for a client experiencing Braxton Hicks contractions at 32 weeks'
gestation. Which of the following should the nurse recommend?
o A. Time contractions hourly
o B. Hydrate and rest in lateral position
o C. Administer tocolytics
, o D. Prepare for labor Rationale: Hydration resolves false labor, promoting uterine
relaxation for fetal growth stability and preventing preterm labor per ACOG
antepartum guidelines.
6. A nurse is evaluating a client for gestational diabetes at 24 weeks' gestation. Which of the
following should the nurse anticipate for screening?
o A. Fasting glucose 126 mg/dL
o B. 1-hour 50g glucose challenge
o C. HbA1c <6.5%
o D. Oral glucose tolerance test Rationale: The 1-hour GCT screens for impaired
glucose tolerance, identifying risks to fetal macrosomia and metabolic stability
per ADA 2025 pregnancy diabetes screening.
7. A nurse is teaching a client about danger signs in the second trimester. Which of the
following should the nurse include?
o A. Mild nausea
o B. Sudden gush of fluid
o C. Fetal movement
o D. Weight gain 1 lb/week Rationale: PROM risks ascending infection and
preterm birth, requiring immediate evaluation for amniotic fluid stability and fetal
membrane integrity per AWHONN high-risk pregnancy care.
8. A nurse is assessing a client at 28 weeks' gestation with preeclampsia. Which of the
following findings should the nurse report?
o A. Blood pressure 130/80 mm Hg
o B. 3+ proteinuria
o C. Ankle edema
o D. Reflexes 2+ Rationale: Proteinuria ≥2+ indicates endothelial dysfunction,
threatening placental perfusion and fetal growth stability; magnesium sulfate
prophylaxis enhances neuromuscular control per ACOG 2025 preeclampsia
management.
9. A nurse is caring for a client with hyperemesis gravidarum. Which of the following
should the nurse administer?
o A. Metoclopramide
o B. Vitamin B6 and doxylamine
o C. Ondansetron only
o D. IV fluids 500 mL/day Rationale: Antiemetic combination alleviates nausea,
preventing dehydration and ketosis for maternal electrolyte stability and fetal
nutrition per ACOG nausea guidelines.
10. A nurse is performing a vaginal exam on a client in labor. Which of the following
indicates +1 station?
o A. Fetal head 1 cm above ischial spines
o B. Fetal head 1 cm below ischial spines
o C. Cervix 1 cm dilated
o D. Effacement 10% Rationale: Station +1 reflects engagement progress, guiding
labor augmentation for cervical dilation stability and fetal descent per AWHONN
intrapartum assessment.
11. A nurse is monitoring a client during the transition phase of labor. Which of the
following should the nurse expect?
, o A. Cervical dilation 4-7 cm
o B. Cervical dilation 8-10 cm
o C. Contractions every 10 min
o D. Urge to push absent Rationale: Transition involves full dilation, with intense
contractions for fetal cardiovascular stability; coaching breathing prevents
maternal exhaustion per Lamaze labor support.
12. A nurse is assessing fetal heart tones during labor. Which of the following indicates cord
prolapse?
o A. Early decelerations
o B. Variable decelerations with bradycardia
o C. Late decelerations
o D. Acceleration absent Rationale: Variable FHR drops signal cord compression,
risking fetal hypoxia; immediate knee-chest position elevates presenting part for
umbilical flow stability per NICHD category III tracing management.
13. A nurse is caring for a client receiving epidural anesthesia. Which of the following
should the nurse monitor?
o A. Blood pressure drop
o B. Hypotension and urinary retention
o C. Hyperglycemia
o D. Tachycardia Rationale: Sympathetic blockade causes hypotension, impairing
uteroplacental perfusion; fluid bolus and left lateral positioning ensure fetal
oxygenation stability per ASA obstetric anesthesia guidelines.
14. A nurse is assisting with a vacuum-assisted delivery. Which of the following should the
nurse ensure?
o A. Maternal pushing during contraction
o B. Cup placement over posterior fontanelle
o C. Three pulls maximum
o D. Forceps backup unnecessary Rationale: Correct cup application avoids
cephalhematoma, promoting safe fetal extraction for head molding stability per
ACOG operative vaginal delivery.
15. A nurse is caring for a newborn immediately after birth. Which of the following is the
first Apgar score component assessed?
o A. Heart rate
o B. Respiratory effort
o C. Muscle tone
o D. Reflexes Rationale: Respiratory effort at 1 minute evaluates airway clearance,
prioritizing newborn ventilation stability per AAP Apgar scoring for resuscitation
needs.
16. A nurse is performing newborn assessment and notes acrocyanosis. Which of the
following should the nurse document?
o A. Central cyanosis
o B. Peripheral cyanosis resolving with warming
o C. Jaundice
o D. Meconium staining Rationale: Acrocyanosis reflects immature circulation,
benign if peripheral and transient, ensuring thermoregulation stability per NANN
newborn skin assessment.
2025/2026 – Verified Answers &
Rationales | A+ Graded Content
1. A nurse is assessing a client at 12 weeks' gestation. Which of the following fetal
development milestones should the nurse expect?
o A. Lanugo formation
o B. Quickening
o C. Lanugo formation
o D. Viable survival Rationale: Quickening (fetal movement perception) occurs
around 12-16 weeks, marking neuromuscular maturity for fetal oxygenation
stability; early detection reassures placental perfusion per ACOG prenatal
milestones.
2. A nurse is teaching a client about fetal development at 8 weeks' gestation. Which of the
following should the nurse include?
o A. Organogenesis complete
o B. Heartbeat detectable via Doppler
o C. Surfactant production
o D. Bone ossification Rationale: Cardiac activity is audible by transvaginal
Doppler at 8 weeks, confirming embryonic viability and circulatory development
stability for early pregnancy monitoring.
3. A nurse is performing Leopold maneuvers on a client at 36 weeks' gestation. Which of
the following positions indicates a breech presentation?
o A. Soft, irregular mass in fundal region
o B. Hard, round mass in fundal region
o C. Fetal back on right side
o D. Small parts on left side Rationale: Breech presents a hard cephalic pole
fundally, guiding external cephalic version for fetal positioning stability and
vaginal delivery optimization per AWHONN intrapartum care.
4. A nurse is assessing fetal heart rate (FHR) during a non-stress test. Which of the
following findings indicates fetal well-being?
o A. Accelerations with movement
o B. Baseline 140/min with variability
o C. Decelerations late
o D. FHR 90/min Rationale: Moderate variability (6-25 bpm) and baseline 110-
160/min reflect autonomic nervous system maturity, ensuring fetal oxygenation
stability per NICHD FHR interpretation.
5. A nurse is caring for a client experiencing Braxton Hicks contractions at 32 weeks'
gestation. Which of the following should the nurse recommend?
o A. Time contractions hourly
o B. Hydrate and rest in lateral position
o C. Administer tocolytics
, o D. Prepare for labor Rationale: Hydration resolves false labor, promoting uterine
relaxation for fetal growth stability and preventing preterm labor per ACOG
antepartum guidelines.
6. A nurse is evaluating a client for gestational diabetes at 24 weeks' gestation. Which of the
following should the nurse anticipate for screening?
o A. Fasting glucose 126 mg/dL
o B. 1-hour 50g glucose challenge
o C. HbA1c <6.5%
o D. Oral glucose tolerance test Rationale: The 1-hour GCT screens for impaired
glucose tolerance, identifying risks to fetal macrosomia and metabolic stability
per ADA 2025 pregnancy diabetes screening.
7. A nurse is teaching a client about danger signs in the second trimester. Which of the
following should the nurse include?
o A. Mild nausea
o B. Sudden gush of fluid
o C. Fetal movement
o D. Weight gain 1 lb/week Rationale: PROM risks ascending infection and
preterm birth, requiring immediate evaluation for amniotic fluid stability and fetal
membrane integrity per AWHONN high-risk pregnancy care.
8. A nurse is assessing a client at 28 weeks' gestation with preeclampsia. Which of the
following findings should the nurse report?
o A. Blood pressure 130/80 mm Hg
o B. 3+ proteinuria
o C. Ankle edema
o D. Reflexes 2+ Rationale: Proteinuria ≥2+ indicates endothelial dysfunction,
threatening placental perfusion and fetal growth stability; magnesium sulfate
prophylaxis enhances neuromuscular control per ACOG 2025 preeclampsia
management.
9. A nurse is caring for a client with hyperemesis gravidarum. Which of the following
should the nurse administer?
o A. Metoclopramide
o B. Vitamin B6 and doxylamine
o C. Ondansetron only
o D. IV fluids 500 mL/day Rationale: Antiemetic combination alleviates nausea,
preventing dehydration and ketosis for maternal electrolyte stability and fetal
nutrition per ACOG nausea guidelines.
10. A nurse is performing a vaginal exam on a client in labor. Which of the following
indicates +1 station?
o A. Fetal head 1 cm above ischial spines
o B. Fetal head 1 cm below ischial spines
o C. Cervix 1 cm dilated
o D. Effacement 10% Rationale: Station +1 reflects engagement progress, guiding
labor augmentation for cervical dilation stability and fetal descent per AWHONN
intrapartum assessment.
11. A nurse is monitoring a client during the transition phase of labor. Which of the
following should the nurse expect?
, o A. Cervical dilation 4-7 cm
o B. Cervical dilation 8-10 cm
o C. Contractions every 10 min
o D. Urge to push absent Rationale: Transition involves full dilation, with intense
contractions for fetal cardiovascular stability; coaching breathing prevents
maternal exhaustion per Lamaze labor support.
12. A nurse is assessing fetal heart tones during labor. Which of the following indicates cord
prolapse?
o A. Early decelerations
o B. Variable decelerations with bradycardia
o C. Late decelerations
o D. Acceleration absent Rationale: Variable FHR drops signal cord compression,
risking fetal hypoxia; immediate knee-chest position elevates presenting part for
umbilical flow stability per NICHD category III tracing management.
13. A nurse is caring for a client receiving epidural anesthesia. Which of the following
should the nurse monitor?
o A. Blood pressure drop
o B. Hypotension and urinary retention
o C. Hyperglycemia
o D. Tachycardia Rationale: Sympathetic blockade causes hypotension, impairing
uteroplacental perfusion; fluid bolus and left lateral positioning ensure fetal
oxygenation stability per ASA obstetric anesthesia guidelines.
14. A nurse is assisting with a vacuum-assisted delivery. Which of the following should the
nurse ensure?
o A. Maternal pushing during contraction
o B. Cup placement over posterior fontanelle
o C. Three pulls maximum
o D. Forceps backup unnecessary Rationale: Correct cup application avoids
cephalhematoma, promoting safe fetal extraction for head molding stability per
ACOG operative vaginal delivery.
15. A nurse is caring for a newborn immediately after birth. Which of the following is the
first Apgar score component assessed?
o A. Heart rate
o B. Respiratory effort
o C. Muscle tone
o D. Reflexes Rationale: Respiratory effort at 1 minute evaluates airway clearance,
prioritizing newborn ventilation stability per AAP Apgar scoring for resuscitation
needs.
16. A nurse is performing newborn assessment and notes acrocyanosis. Which of the
following should the nurse document?
o A. Central cyanosis
o B. Peripheral cyanosis resolving with warming
o C. Jaundice
o D. Meconium staining Rationale: Acrocyanosis reflects immature circulation,
benign if peripheral and transient, ensuring thermoregulation stability per NANN
newborn skin assessment.
