ATI RN
Assessment of High Risk Pregnancy NCLEX Questions Questions
Question 1 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 2 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 3 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 4 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.
Question 5 of 5
The nurse is preparing to assist with the insertion of an intrauterine pressure catheter and a fetal spiral electrode. What is required for proper placement by the practitioner? Select all that apply.
Correct Answer: A
Rationale: Correct Answer: A - Rupture of membranes Rationale: 1. Rupture of membranes is necessary for the insertion of intrauterine pressure catheter and fetal spiral electrode. 2. It allows safe passage of the catheter and electrode into the uterus. 3. Without ruptured membranes, there is a risk of infection and difficulty in inserting the devices. Summary: - Choice B (Dilated cervix) is not required for the insertion of these devices. - Choice C (Vertex fetus) is not a factor in the insertion process. - Choice D (Moderate variability) is related to fetal heart rate monitoring, not device insertion.