ATI RN
Assessment of High Risk Pregnancy NCLEX Questions Questions
Question 1 of 5
A 1-week-postpartum client calls her obstetrician’s office and states, 'I am a breastfeeding mother and my nipples are cracked and bleeding.' Which of the following comments by the nurse is appropriate at this time?
Correct Answer: D
Rationale: The correct answer is option D: "Lanolin cream applied after each feeding will help you to heal." This option is correct because lanolin cream is a safe and effective treatment for cracked and bleeding nipples in breastfeeding mothers. Lanolin helps to soothe and moisturize the skin, promoting healing without the need to interrupt breastfeeding. Option A is incorrect because while it is important for the client to be seen by a healthcare provider, it is not necessary to do so immediately in this case as the issue can be managed at home. Option B is incorrect as there is no need for the mother to pump and dump her milk for a week due to the presence of blood. Breast milk is still safe for the baby to consume even if the mother's nipples are bleeding. Option C is incorrect because using hydrogen peroxide on the nipples can be too harsh and drying, potentially causing further irritation and delaying healing. In an educational context, it is crucial for nurses and healthcare providers to have a good understanding of common issues faced by breastfeeding mothers and appropriate interventions to support them. Providing accurate information and guidance can help mothers overcome challenges and continue breastfeeding successfully.
Question 2 of 5
A breastfeeding client asks the nurse to make sure that her newborn is positioned and latched well at the breast. Which of the following assessments would indicate that the baby is poorly latched?
Correct Answer: C
Rationale: In this scenario, option C, "The baby's lower lip is curled under," indicates that the baby is poorly latched. This is because a proper latch involves the baby taking in a good portion of the areola along with the nipple, ensuring effective milk transfer and preventing nipple soreness or damage. When the baby's lower lip is curled under, it may result in shallow latch, leading to ineffective feeding and potential issues for both the baby and the mother. Option A, "The baby swallows after every suckle," is incorrect because swallowing after every suckle is a positive sign of effective breastfeeding and milk transfer. Option B, "The baby's body is facing the mother's body," is also incorrect as proper positioning involves the baby facing the breast directly for a good latch. Option D, "The baby is lying at the level of the mother's breasts," is not directly related to latch assessment but rather refers to positioning, which may vary depending on the comfort of the mother and the baby. Educationally, understanding the signs of a good latch is crucial for promoting successful breastfeeding, ensuring adequate nutrition for the newborn, and preventing issues like poor weight gain or nipple pain for the mother. Nurses play a key role in supporting breastfeeding mothers by providing guidance on proper latch techniques and troubleshooting any difficulties that may arise during breastfeeding sessions.
Question 3 of 5
The nurse is working with a pregnant woman who states that she is a vegan. Which of the following actions by the nurse is appropriate?
Correct Answer: B
Rationale: The correct answer is B: Refer the woman to a nutritionist for diet counseling. This option is appropriate because it acknowledges the unique dietary needs of a vegan pregnant woman and the importance of ensuring she receives adequate nutrition during her pregnancy. Referring her to a nutritionist will provide her with expert guidance on how to maintain a balanced vegan diet that meets her nutritional requirements and supports a healthy pregnancy. Option A is incorrect as it is not necessary for the pregnant woman to consume animal protein if she is following a well-planned vegan diet that includes plant-based sources of protein. Option C is misleading as while cashews and coconut are good sources of certain nutrients, they may not provide all the essential nutrients needed during pregnancy. Option D is incorrect as it assumes the woman is willing to eat eggs and milk, which may not align with her dietary beliefs. In an educational context, it is crucial for nurses to be aware of the diverse dietary preferences of pregnant women and provide individualized care that respects their choices while promoting optimal health outcomes. Referring to a nutritionist ensures that the pregnant woman receives tailored advice that considers her vegan lifestyle and pregnancy needs.
Question 4 of 5
The nurse is caring for a baby whose blood type is A+ (positive) and direct Coombs’ test is + (positive), and whose mother’s blood type is O+ (positive). Which of the following nursing diagnoses is appropriate for this baby?
Correct Answer: A
Rationale: In this scenario, the correct nursing diagnosis for the baby with A+ blood type and a positive direct Coombs' test whose mother is O+ is "Risk for injury to the central nervous system." This baby is at risk for hemolytic disease of the newborn (HDN) due to the incompatibility between the mother's and baby's blood types. HDN can lead to severe complications, including kernicterus, which is a type of brain damage resulting from severe jaundice. Therefore, monitoring for signs of jaundice and central nervous system complications is crucial. Option B, "Risk for fluid volume deficit," is incorrect as it does not directly relate to the situation described. Option C, "Risk for interrupted family processes," is not the priority nursing diagnosis when dealing with a high-risk medical situation like HDN. Option D, "Risk for impaired parent-infant attachment," is also less relevant in this acute medical context. Educationally, understanding the pathophysiology of HDN and the implications of blood type incompatibility is vital for nurses caring for infants at risk. Recognizing the potential consequences of HDN and prioritizing appropriate nursing interventions can significantly impact the outcomes for these high-risk newborns.
Question 5 of 5
A 36-week-gestation client is having an amniocentesis. For which of the following reasons is the test likely being conducted?
Correct Answer: C
Rationale: In a high-risk pregnancy scenario, conducting an amniocentesis at 36 weeks of gestation is primarily to assess fetal lung maturation (Option C). This test helps determine if the baby's lungs are developed enough to function properly outside the womb. Option A, genetic evaluation, is typically done earlier in pregnancy and not the primary reason for a late-term amniocentesis. Option B, assessment of intrauterine growth restriction, would be assessed through other means, such as ultrasound measurements, rather than an amniocentesis. Option D, hormonal studies, is not the primary purpose of an amniocentesis in this scenario. From an educational perspective, understanding the indications for different prenatal tests is crucial for nursing students and healthcare professionals caring for pregnant women. Knowing when and why specific tests are done helps in providing holistic care and appropriate interventions for both the mother and the fetus. It also highlights the importance of timing and rationale behind diagnostic procedures in high-risk pregnancies to ensure optimal outcomes.