ATI RN
Assessment of High Risk Pregnancy NCLEX Questions Questions
Question 1 of 5
A young man is planning to use the condom as a contraceptive device. The nurse should teach him that which of the following actions is needed to maximize the condom's effectiveness?
Correct Answer: A
Rationale: In the context of high-risk pregnancy, it is crucial for the nurse to educate the young man on maximizing the effectiveness of condoms as a contraceptive method. The correct answer, option A, to use only water-soluble lubricants, is essential to ensure the integrity of the condom. Oil-based lubricants can weaken latex condoms, increasing the risk of breakage and reducing effectiveness in preventing pregnancy and sexually transmitted infections (STIs). Option B, using natural lambskin condoms, is not the best choice for high-risk pregnancies as they do not protect against STIs due to their porous nature. Option C, applying the condom to a flaccid penis, is incorrect as it may lead to improper fit and slippage during intercourse, compromising effectiveness. Option D, applying it tightly to the tip of the penis, can also increase the risk of breakage due to friction during intercourse. Educationally, this question highlights the importance of proper condom use in preventing unwanted pregnancies and STIs, especially in high-risk pregnancy situations where additional precautions may be necessary. Teaching individuals about the correct use of condoms and factors that can impact their effectiveness is crucial in promoting safe sexual practices and reproductive health.
Question 2 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 3 of 5
A laboring woman, G4 P3003, who was 6 cm dilated 1 hour ago cries, 'Hurry. I have to go to the bathroom to have a bowel movement.' The nurse notes that there is an increase in bloody show. Which of the following actions by the nurse is appropriate?
Correct Answer: A
Rationale: In this scenario, the appropriate action for the nurse to take is option A: Assess cervical dilation. This is the correct choice because the woman's statement about needing to have a bowel movement, coupled with the increase in bloody show, suggests that she may be experiencing the urge to push. Assessing cervical dilation will help the nurse determine if the woman is fully dilated and ready to begin pushing. Option B: Helping the woman to the bathroom is incorrect because the signs and symptoms described indicate a need for cervical assessment rather than a bathroom visit. Option C: Asking the woman if she needs pain medicine is also incorrect at this moment because the priority is to assess the progress of labor and ensure the safety of both the mother and the baby. Option D: Checking the fetal heart rate is not the immediate priority in this situation. While monitoring the fetal heart rate is important during labor, the woman's symptoms suggest a need for cervical assessment first. Educationally, this question highlights the importance of recognizing signs of labor progression and understanding the appropriate nursing actions to take in response to these signs. It reinforces the significance of timely and accurate assessments in high-risk pregnancy situations to ensure optimal maternal and fetal outcomes.
Question 4 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 5 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.