ATI RN
Assessment of High Risk Pregnancy NCLEX Questions Questions
Question 1 of 5
A baby is exhibiting signs of neonatal abstinence syndrome. Which action would be appropriate for the nursery nurse to make?
Correct Answer: A
Rationale: The correct answer is A) Cover the baby with at least two blankets. Neonatal abstinence syndrome (NAS) occurs in babies exposed to drugs in utero, leading to withdrawal symptoms after birth. Swaddling the baby with blankets provides a comforting, cocoon-like environment that helps reduce symptoms like tremors and irritability typical of NAS. Option B) Stimulating the baby with rattles is incorrect because excessive stimulation can aggravate withdrawal symptoms in babies with NAS, leading to increased discomfort and distress. Option C) Playing soft classical music in the nursery is also inappropriate as loud noises or music can overstimulate the baby and worsen withdrawal symptoms. Option D) Attaching a mobile to the crib is not the best choice for a baby with NAS as it may provide unnecessary visual stimulation, potentially exacerbating the symptoms. In an educational context, understanding the appropriate care for infants with NAS is crucial for nurses working in neonatal units. Providing a calm, soothing environment through techniques like swaddling can help alleviate withdrawal symptoms and promote the well-being of these vulnerable newborns.
Question 2 of 5
A woman asks the nurse to recommend the best douche for use after menstruation. Which of the following responses by the nurse is appropriate?
Correct Answer: B
Rationale: The correct response, option B, "It is really best for women not to douche," is appropriate for several reasons. Douching is not recommended as it can disrupt the natural balance of bacteria in the vagina, leading to infections or other complications, especially in high-risk pregnancy situations. By advising against douching, the nurse promotes the maintenance of vaginal health and reduces the risk of potential harm to the woman and her developing fetus. Option A, suggesting tap water with white vinegar, is incorrect because the acidity of vinegar can disrupt the vaginal pH balance, leading to irritation or infection. Option C, stating that any over-the-counter douche is satisfactory, is incorrect as it promotes a practice that is generally discouraged. Option D is also incorrect as douching during menstruation can increase the risk of introducing bacteria into the uterus, potentially leading to infections or other complications. In an educational context, it is crucial for nurses to provide evidence-based recommendations to promote the health and well-being of pregnant women. Teaching about the potential risks of douching and emphasizing the importance of maintaining the natural vaginal flora can help prevent complications and support optimal pregnancy outcomes. Nurses play a key role in educating women about safe practices during pregnancy, including avoiding unnecessary interventions like douching.
Question 3 of 5
A nurse sees an overweight woman looking at the babies through the nursery window. The woman asks the nurse when the babies go to their mothers for feedings and about the location of the nearest stairwell. Which of the following replies by the nurse is most appropriate at this time?
Correct Answer: B
Rationale: The most appropriate response by the nurse in this situation is option B: "Please let me escort you to the mother’s room you are here to visit." This response is the best choice because it addresses the woman's inquiries directly and offers her assistance and guidance to the intended destination. Option A is incorrect because it provides vague information that may not address the woman's concerns effectively. Option C is incorrect as it inaccurately states that the babies are with their mothers for the majority of the day, which may not be the case in a hospital setting. Option D is also incorrect as it does not address the woman's questions and instead provides unrelated information about visitor preferences. In an educational context, it is essential for nurses to respond to patients and visitors with empathy, clear communication, and assistance when needed. This scenario highlights the importance of effective communication skills and providing support to individuals in healthcare settings, especially in high-stress situations such as a high-risk pregnancy unit.
Question 4 of 5
A male baby is born with scant amounts of vernix caseosa in his axillae and groin, scant amounts of lanugo on his shoulders, testes in his scrotum, and a strong suck. The nurse would estimate that the baby is which of the following gestational ages?
Correct Answer: D
Rationale: In this scenario, the correct answer is option D) 38 weeks gestational age. This baby is exhibiting characteristics that are typical of a full-term newborn. The presence of scant vernix caseosa and lanugo, descended testes, and strong sucking reflex are all indicative of a baby at around 38 weeks of gestation. Option A) 22 weeks is incorrect as a baby born at 22 weeks would not have these physical characteristics developed to the extent described in the scenario. Option B) 28 weeks is also incorrect as these features would not typically be present in a baby born at this gestational age. Option C) 32 weeks is incorrect as well since the described characteristics are more consistent with a baby closer to full term. Educationally, understanding the physical characteristics associated with different gestational ages is crucial for healthcare providers working with newborns, especially in high-risk pregnancy situations. Recognizing these signs can help determine appropriate care and interventions for newborns based on their gestational age.
Question 5 of 5
A neonate in the nursery, whose mother had no prenatal care, has been diagnosed with macrosomia. For which of the following signs/symptoms should the nurse carefully monitor this baby?
Correct Answer: B
Rationale: In the case of a neonate with macrosomia, the correct sign/symptom to monitor is jitters (Option B). Macrosomia refers to a large baby at birth, which can be a result of maternal diabetes or excessive weight gain during pregnancy. Jitters in a neonate can be indicative of hypoglycemia, a common complication in babies born to diabetic mothers or with macrosomia. Monitoring for jitters is crucial as untreated hypoglycemia can lead to serious consequences such as seizures or brain damage. Jaundice (Option A) is a common condition in newborns due to immature liver function and is not directly related to macrosomia. Blepharitis (Option C) and strabismus (Option D) are eye conditions that are not typically associated with macrosomia in neonates. Educationally, understanding the signs and symptoms associated with high-risk pregnancies and their potential complications is vital for nurses caring for neonates. Recognizing the signs of hypoglycemia early on and taking appropriate actions can prevent further complications and ensure the baby's well-being. Regular monitoring and assessment skills are essential in providing safe and effective care for neonates, especially those born to high-risk pregnancies.