ATI RN
Assessment of High Risk Pregnancy NCLEX Questions Questions
Question 1 of 5
A client who is 18 weeks’ gestation has been diagnosed with a hydatiform mole (gestational trophoblastic disease). In addition to vaginal loss, which of the following signs/symptoms would the nurse expect to see?
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 2 of 5
An NST is performed on a client who is G6T3P1A1L4 38 weeks gestation. After the patient has been on the external monitor for 30 minutes, the nurse sees three fetal heart rate accelerations of 15 bpm lasting 5 seconds in association with fetal movement. The nurse documents this finding as which of the following?
Correct Answer: B
Rationale: The correct answer is B: A reactive NST. This is because the NST shows three fetal heart rate accelerations of 15 bpm lasting 5 seconds each, in association with fetal movement. A reactive NST indicates a normal response, which is characterized by the presence of fetal heart rate accelerations associated with fetal movement. This is a reassuring finding, suggesting fetal well-being. Choice A (Unsatisfactory) is incorrect because the description of the findings indicates a satisfactory response. Choice C (A nonreactive nonstress test) is incorrect because the test showed accelerations in response to fetal movements, which is not consistent with a nonreactive test. Choice D (Equivocal suspicious) is incorrect as there is no indication of uncertainty or suspicion in the findings described.
Question 3 of 5
The nurse is caring for a client with a suspected breech presentation. When the nurse performs Leopold's maneuvers, which maneuvers determine the fetal presentation? Select all that apply.
Correct Answer: C
Rationale: First, the nurse applies gentle pressure just above the symphysis pubis to determine the presenting part (First). Second, the nurse palpates the sides of the uterus to identify the fetal back and small parts (Second). Third, Pawlik’s maneuver involves locating the fetal head in the fundus to confirm the fetal presentation. This maneuver determines the fetal presentation definitively (Correct - C). Fourth, the nurse feels for the fetal buttocks or cephalic prominence to determine the position of the back or head (Fourth). Pawlik's maneuver is crucial in identifying the fetal presentation accurately, making it the correct answer. Other choices are incorrect as they do not directly determine the fetal presentation like Pawlik's maneuver does.
Question 4 of 5
The nurse is caring for a pregnant client who was sent to the hospital for a biophysical profile. She is 37 weeks gestation with her second child, has gestational diabetes, and complains of decreased fetal movement for the last 24 hours. Which action should the nurse take first?
Correct Answer: D
Rationale: The correct answer is D: Place on fetal monitor. This action is crucial to assess the fetal well-being and monitor the baby's heart rate and movements. It helps in determining if the baby is in distress and requires immediate intervention. Performing vital signs (A) is important but not the priority in this situation. Calling the physician (B) can be done after the initial assessment on the fetal monitor. Performing glucose (C) is not the priority when the main concern is the well-being of the baby.
Question 5 of 5
The nurse is caring for a client who had a contraction stress test. Which change in assessment requires immediate notification of the health care provider?
Correct Answer: B
Rationale: The correct answer is B because late decelerations with at least 50% of contractions indicate fetal distress and potential hypoxia. This requires immediate notification of the healthcare provider for further evaluation and intervention. No late decelerations (choice A) are normal. Accelerations with contractions (choice C) are reassuring. No contractions produced (choice D) would indicate an inadequate test and require reevaluation.