ATI RN
Assessment of High Risk Pregnancy NCLEX Questions Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The nurse is caring for a client being monitored for oligohydramnios. The NST is nonreactive. Which findings correlate with these results?
Correct Answer: A
Rationale: Step 1: Oligohydramnios indicates decreased amniotic fluid, which can lead to fetal hypoxia. Step 2: Nonreactive NST suggests lack of appropriate fetal heart rate accelerations in response to fetal movement. Step 3: Less than 2 accelerations in 20-40 minutes is consistent with nonreactive NST due to decreased fetal movement. Step 4: Choice A is correct as it reflects the expected findings in a nonreactive NST scenario. Summary: - Choice B: The criteria for accelerations are too high for a nonreactive NST. - Choice C: The criteria for accelerations are too low for a nonreactive NST. - Choice D: Four accelerations in the given time frame do not correlate with a nonreactive NST.
Question 5 of 5
A client presents to Labor & Delivery for an ultrasound at 16 weeks gestation for vaginal bleeding. She asks the nurse if the procedure will harm her baby. Which is appropriate for the nurse to tell the client?
Correct Answer: B
Rationale: The correct answer is B: "Ultrasounds use sound waves to view your baby, not radiation, so the procedure will not harm your baby." Rationale: 1. Ultrasound uses sound waves, not radiation, to create images of the baby in the womb. 2. The sound waves are considered safe for both the mother and the developing baby. 3. There is no evidence to suggest that ultrasound procedures pose any harm to the pregnancy. 4. It is important to reassure the client that the ultrasound is a routine procedure and will not harm the baby. Summary: Choice A is incorrect because it wrongly implies that the ultrasound could potentially harm the baby due to the existing bleeding, which is not true. Choice C is incorrect as it does not provide specific information regarding the safety of ultrasound during pregnancy. Choice D is incorrect as it lacks the specific information about the safety of ultrasound and relies on a general statement about the doctor's intentions.