ATI RN
Assessment of High Risk Pregnancy NCLEX Questions Questions
Question 1 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 2 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 3 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 4 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.
Question 5 of 5
The nurse is caring for a 45-year-old client who is scheduled to have a chorionic villus sampling. Which information is most important for the nurse to obtain from the client before the procedure?
Correct Answer: D
Rationale: The correct answer is D: Maternal bleeding disorders. This information is crucial before a chorionic villus sampling to assess the risk of excessive bleeding during the procedure due to potential clotting issues. Maternal bleeding disorders can increase the risk of complications during the procedure. A: NPO status is not as critical for this procedure as it does not typically require fasting. B: Blood type and Rh are important for other purposes but not specifically needed before a chorionic villus sampling. C: Weeks of gestation is important for determining the timing of the procedure but does not directly impact the safety or success of the procedure.