ATI RN
Assessment of High Risk Pregnancy NCLEX Questions Questions
Question 1 of 5
The nurse receives a phone call from a pregnant patient who states she has not felt the baby move. Identify the first question for the nurse to ask the patient.
Correct Answer: D
Rationale: The correct first question for the nurse to ask the patient is D: When was the last time you felt the baby move? This question is crucial because it helps assess the fetal well-being and can indicate any potential issues with the baby's health or development. It allows the nurse to determine if there has been a recent decrease in fetal movements, which could be a sign of distress. Asking about vaginal bleeding or discharge (choices A and B) may not provide immediate insight into the baby's well-being. Question C is relevant but not as urgent as knowing when the baby was last felt moving.
Question 2 of 5
The nurse is measuring the fundal height of a patient who is at 34 weeks of gestation. What fundal height measurement is expected for a patient who is at 34 weeks of gestation?
Correct Answer: C
Rationale: The correct answer is C (37 cm) because at 34 weeks of gestation, the fundal height measurement should be approximately equal to the number of weeks of gestation in centimeters. This is known as the "fundal height equals gestational age" rule. Therefore, at 34 weeks, the expected fundal height measurement should be around 34 cm. Option C (37 cm) is the closest to this expected measurement. Options A, B, and D are incorrect as they do not align with the fundal height expected at 34 weeks of gestation. Option A (31 cm) is too low, Option B (33 cm) is also lower than expected, and Option D (38 cm) is too high for 34 weeks of gestation.
Question 3 of 5
The nurse is discussing pregnancy concerns with a patient in the third trimester of pregnancy. What warning sign should the nurse teach the patient to report immediately to the health-care provider?
Correct Answer: B
Rationale: The correct answer is B: decreased fetal movement. This warning sign is crucial in the third trimester as it could indicate fetal distress or other complications requiring prompt medical attention. Decreased fetal movement can be a sign of potential problems with the baby's health and should not be ignored. Chronic constipation (A), early evening fatigue (C), and loss of appetite (D) are common pregnancy symptoms but are not typically considered urgent warning signs that require immediate reporting to the healthcare provider. It is important for the nurse to emphasize the significance of monitoring fetal movements and seeking medical advice promptly if there is a noticeable decrease.
Question 4 of 5
The nurse is completing the family assessment on a patient at 10 weeks of gestation. What data are included in the family assessment? Select all that apply.
Correct Answer: A
Rationale: The correct answer is A: annual income. This data is crucial for assessing the family's financial resources and potential impact on the patient's health and well-being during pregnancy. Annual income can help identify possible financial stressors that may affect access to healthcare, nutrition, and overall prenatal care. B: Total number of cousins is not typically part of a family assessment during pregnancy and does not directly impact the patient's prenatal care. C: Number of people living in the household is important for understanding the household dynamics, but it may not be directly related to the patient's prenatal care needs. D: Identifying the person in the household who makes major decisions is important for understanding family dynamics, but it may not directly impact the patient's prenatal care.
Question 5 of 5
Which analysis of maternal serum is the best predictor of chromosomal abnormalities in the fetus?
Correct Answer: B
Rationale: The correct answer is B: Multiple-marker screening. This analysis measures levels of certain proteins and hormones in maternal serum to assess the risk of chromosomal abnormalities in the fetus. It is considered the best predictor because abnormal levels of these markers can indicate conditions like Down syndrome. Biophysical profile (A) assesses fetal well-being but does not directly predict chromosomal abnormalities. Lecithin-to-sphingomyelin ratio (C) is used to assess fetal lung maturity, not chromosomal abnormalities. Blood type and crossmatch (D) are important for identifying Rh incompatibility but do not predict chromosomal abnormalities.