ATI RN
Assessment of High Risk Pregnancy NCLEX Questions Questions
Question 1 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 2 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 3 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 4 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 5 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.