ATI RN
Assessment of High Risk Pregnancy NCLEX Questions Questions
Question 1 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 2 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.
Question 3 of 5
A woman has been diagnosed with chlamydia. The nurse would expect the client to complain of which of the following signs/symptoms?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) No signs or symptoms. Chlamydia is a sexually transmitted infection that often presents asymptomatically, especially in women. This is a crucial point to emphasize in high-risk pregnancy assessments because pregnant women with untreated chlamydia are at risk of complications like preterm birth and neonatal infections. Option B) Painful lesions on the labia is more indicative of genital herpes rather than chlamydia. Option C) Foul-smelling discharge is commonly associated with bacterial vaginosis or trichomoniasis, not chlamydia. Option D) Severe lower abdominal pain is a symptom more commonly seen in conditions like pelvic inflammatory disease (PID) rather than chlamydia. Educationally, this question highlights the importance of understanding the varied presentations of different sexually transmitted infections, especially in the context of high-risk pregnancies. It underscores the need for healthcare providers to conduct thorough assessments and testing, even in the absence of symptoms, to ensure the health of both the mother and the developing fetus.
Question 4 of 5
The nurse is providing patient teaching to a client who plans to bottle feed her newborn infant. Which of the following information should be included in the education session?
Correct Answer: B
Rationale: In this scenario, option B is the correct answer. It is crucial to educate the client that if the bottle nipple is not filled throughout the feeding, the baby may intake a large amount of air, leading to potential issues like gas or colic. This knowledge helps prevent discomfort for the infant and promotes proper feeding techniques. Options A, C, and D are incorrect for several reasons. Option A provides incorrect guidance on burping frequency, as it is recommended to burp the baby more frequently, not just after every 3 ounces. Option C advises heating formula in the microwave, which can create hot spots and burn the baby's mouth, posing a safety risk. Option D suggests propping the bottle, which increases the risk of aspiration, choking, and may also lead to overfeeding. From an educational perspective, it is essential to emphasize evidence-based practices in patient teaching to ensure optimal outcomes for both the infant and the mother. Providing accurate information on bottle feeding techniques enhances the client's knowledge and promotes the well-being of the newborn. It is crucial for nurses to deliver clear, concise, and accurate instructions to empower parents in caring for their infants effectively.
Question 5 of 5
Using the graph below, of the following weights, how many grams would a 34-week neonate need to weigh to be labeled appropriate-for-gestational age?
Correct Answer: C
Rationale: The correct answer is option C) 2,900 grams. In assessing a neonate's weight as appropriate-for-gestational age, we consider the expected weight range based on the gestational age. At 34 weeks, a neonate is expected to weigh around 2,900 grams, which falls within the normal range for that gestational age. Option A) 500 grams is too low for a 34-week neonate and would indicate a very low birth weight, which is not appropriate for the gestational age. Option B) 1,700 grams is also below the expected weight range for a 34-week neonate and would be classified as small for gestational age. Option D) 4,100 grams is above the expected weight range for a 34-week neonate and would be considered large for gestational age, not appropriate for the gestational age. Understanding neonatal weight categories is crucial in assessing the overall health and development of the newborn. This knowledge is essential for healthcare providers involved in the care of high-risk pregnancies to monitor and intervene appropriately to ensure optimal outcomes for both the mother and the newborn.