ATI RN
Assessment of High Risk Pregnancy NCLEX Questions Questions
Question 1 of 5
A client's amniocentesis results are reported as 45, X. How should the nurse interpret these findings?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) The girl will be short and sterile. Rationale: 1. The presence of 45, X indicates Turner syndrome, where a female is missing part or all of one X chromosome. This condition is associated with short stature and sterility due to ovarian dysgenesis. 2. Option A is incorrect as having Turner syndrome does not automatically mean the fetus is nonviable. With appropriate medical care, individuals with Turner syndrome can lead healthy lives. 3. Option B is incorrect because Turner syndrome is a chromosomal abnormality, not a normal female karyotype (46, XX). 4. Option C is incorrect as Turner syndrome does not result in hermaphroditism. It specifically affects females due to missing or incomplete X chromosome. Educational Context: Understanding karyotypes and genetic disorders like Turner syndrome is crucial in high-risk pregnancy assessment. Nurses must interpret amniocentesis results accurately to provide appropriate education and support to families facing genetic conditions. This knowledge helps in anticipating and addressing potential health concerns for the mother and fetus, ensuring comprehensive care throughout the pregnancy and beyond.
Question 2 of 5
When providing contraceptive counseling to a woman, which of the following factors should the nurse consider? Select all that apply.
Correct Answer: A
Rationale: In the context of providing contraceptive counseling to a woman, considering various factors is crucial for ensuring safe and effective decision-making. Age is a significant factor as it can influence the choice of contraceptives due to physiological changes and risk factors associated with different age groups. Obstetric history is also important as it can impact the selection of contraceptives based on past pregnancy outcomes and complications. Religious beliefs play a role in contraceptive decision-making for some individuals, but it is not a universal factor that applies to all women. Employment, while important in terms of practicality and lifestyle considerations, is not directly linked to the selection of contraceptives. Educationally, understanding the rationale behind considering age and obstetric history in contraceptive counseling helps nurses tailor their approach to meet the individual needs of each woman. It emphasizes the importance of a holistic assessment to provide personalized care that aligns with the patient's unique circumstances and preferences.
Question 3 of 5
A woman, contracting every 3 min 60 seconds, suddenly develops an amniotic fluid embolism. Which of the following signs/symptoms would the nurse observe?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Chest pain with dyspnea and cyanosis. An amniotic fluid embolism is a rare but serious obstetric emergency where amniotic fluid, fetal cells, or other debris enter the maternal bloodstream. This can lead to a cascade of events, including respiratory distress, chest pain, and cyanosis due to a sudden blockage in the pulmonary vasculature, leading to pulmonary embolism and subsequent cardiovascular collapse. Option A) Sudden gush of fluid from the vagina is more indicative of a rupture of membranes or premature rupture of membranes, which is not directly related to an amniotic fluid embolism. Option B) Intense and unrelenting uterine pain is more typical of conditions like placental abruption or uterine rupture, rather than an amniotic fluid embolism. Option C) Precipitous dilation and expulsion of the fetus is not a typical sign of an amniotic fluid embolism, as this condition primarily affects the maternal cardiovascular and respiratory systems rather than directly impacting the progress of labor. Educationally, understanding the signs and symptoms of high-risk pregnancy complications like amniotic fluid embolism is crucial for nurses and healthcare providers working in obstetric settings. Recognizing these signs promptly can lead to timely interventions and potentially save the lives of both the mother and the baby.
Question 4 of 5
On the third postpartum day a client tells the nurse that she feels sad and that she cries easily. The nurse should explain about which of the following?
Correct Answer: A
Rationale: The correct answer is option A: "These feelings are normal and should diminish when the baby is a week or so old." This answer is correct because the client is likely experiencing postpartum blues, a common and temporary condition that affects many women after giving birth. These feelings of sadness and crying easily are often due to hormonal changes, lack of sleep, and the stress of adjusting to a new baby. It is important for the nurse to reassure the client that these feelings are normal and usually resolve on their own within a week or two. Option B is incorrect because prescribing an antidepressant for postpartum blues is not typically the first-line treatment. Postpartum depression, which is more severe and persistent, may require antidepressant medication, but in this scenario, the client is likely experiencing normal postpartum blues. Option C is incorrect because simply focusing on having a healthy baby will not necessarily make the feelings of sadness disappear. While gratitude and positive thinking can be helpful, postpartum blues are a complex issue that may not be resolved by shifting focus alone. Option D is incorrect because the client's feelings of sadness are not solely dependent on being surrounded by family and friends. While social support is important, postpartum blues are a common physiological and emotional response to childbirth that may not be alleviated solely by external factors. Educationally, this question highlights the importance of recognizing and addressing postpartum emotional changes in new mothers. Nurses play a crucial role in educating clients about the range of emotions they may experience postpartum and providing support and guidance to help them navigate this challenging period.
Question 5 of 5
A nurse notes that a baby is lying in a crib in the tonic neck position. In which of the following positions is the baby lying?
Correct Answer: A
Rationale: The correct answer is A) One of the baby's arms and one of its legs are extended to the same side the baby's head is facing. This position describes the tonic neck reflex, also known as the fencing position. In this position, when the baby's head is turned to one side, the arm and leg on that side extend while the opposite arm and leg flex. This reflex is important for assessing neurological development in infants. Option B) describes head tilt, which is not related to the tonic neck reflex. Option C) describes the opisthotonos position, which is a hyperextended posture seen in conditions like meningitis. Option D) describes the asymmetric tonic neck reflex, where the body arches to one side when the baby is lying prone. Understanding these infant reflexes is crucial for healthcare professionals working with newborns as they provide insights into the infant's neurological status and development. Recognizing and interpreting these reflexes help in early identification of any potential issues and appropriate interventions.