ATI RN
Assessment of High Risk Pregnancy NCLEX Questions Questions
Question 1 of 5
A 6-month-old child has been diagnosed with a significant hearing loss. Which of the following complications that occurred immediately after delivery could have resulted in this condition?
Correct Answer: D
Rationale: The correct answer is D) Kernicterus. Kernicterus is a condition caused by severe hyperbilirubinemia leading to bilirubin deposition in the brain, which can result in significant neurological damage, including hearing loss. In newborns, high levels of unconjugated bilirubin can cross the blood-brain barrier due to an immature liver function, leading to kernicterus if left untreated. Option A) Necrotizing enterocolitis is a condition involving intestinal inflammation and necrosis, which does not directly lead to hearing loss in a child. Option B) Hypoglycemia, while a serious condition in newborns, does not typically result in hearing loss as a direct complication. Option C) Bronchopulmonary dysplasia is a lung disease seen in premature infants and is not associated with causing hearing loss in a child. Educationally, understanding the pathophysiology of kernicterus and its association with hyperbilirubinemia is crucial for healthcare professionals caring for newborns. Early recognition, monitoring, and treatment of hyperbilirubinemia can prevent complications like kernicterus and its long-term consequences, including hearing loss. This knowledge is essential for nurses, midwives, and physicians working in neonatal care settings to ensure optimal outcomes for newborns.
Question 2 of 5
A nurse should monitor a client who is postpartum from a forceps delivery for which of the following complications?
Correct Answer: D
Rationale: In a postpartum client following a forceps delivery, monitoring for infection is crucial due to the increased risk of developing infections such as endometritis or wound infections. This risk is higher in forceps deliveries due to the potential tissue trauma associated with the use of forceps during delivery. Option A, placental abruption, is not typically a complication of forceps delivery but rather a risk during pregnancy or labor itself. Option B, seizure, may be related to conditions like eclampsia but is not directly associated with forceps delivery. Option C, idiopathic thrombocytopenia, is not a common complication following forceps delivery. Understanding the specific risks and complications associated with different modes of delivery is essential for nurses caring for postpartum clients. By monitoring for signs of infection, nurses can promptly intervene and provide appropriate treatment, promoting optimal recovery and outcomes for the mother.
Question 3 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 4 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 5 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.