ATI RN
Assessment of High Risk Pregnancy NCLEX Questions Questions
Question 1 of 5
Which of the following features would the nurse expect to be absent in an 8-week-gestation embryo?
Correct Answer: C
Rationale: In this question, the correct answer is C) Fully formed genitalia. At 8 weeks of gestation, the embryo is in the early stages of development and the genitalia are not fully formed. A) A four-chambered heart develops around 5-8 weeks, so it would be expected in an 8-week-gestation embryo. B) Fingers and toes start to form around 6-8 weeks, so they would also be present. D) Facial features begin to develop around 8 weeks as well, so they would be expected. Educationally, understanding the timeline of embryonic development is crucial in the field of pharmacology, especially in high-risk pregnancy scenarios where medications can have significant effects on fetal development. This knowledge helps nurses and healthcare providers assess the normal progression of fetal development and identify any abnormalities that may arise.
Question 2 of 5
Young pregnant adolescents have increased nutritional needs as compared with pregnant adults. Which of the following foods would meet those needs?
Correct Answer: B
Rationale: In the context of high-risk pregnancy, young pregnant adolescents have increased nutritional needs due to their own growth requirements in addition to supporting fetal development. The correct answer, B) Cheeseburger, is high in protein, iron, calcium, and healthy fats, which are essential for the increased demands of pregnancy in young adolescents. Protein is crucial for tissue growth and repair, iron helps prevent anemia common in pregnancy, calcium supports bone development, and healthy fats are important for brain and organ development in the fetus. Option A) Banana, while nutritious, lacks the complete range of nutrients needed to meet the increased demands of pregnancy, especially for young adolescents. Option C) Strawberries are a good source of vitamin C and fiber but do not provide the necessary protein, iron, and calcium in sufficient amounts. Option D) Rice is a carbohydrate-rich food but lacks the essential nutrients like protein and iron needed for the increased requirements of a high-risk pregnancy in young adolescents. Educationally, this question highlights the importance of understanding the specific nutritional needs of different populations, especially in high-risk scenarios like young pregnant adolescents. It emphasizes the significance of a balanced diet rich in essential nutrients during pregnancy to support both maternal and fetal health. This rationale underscores the critical role of nutrition in mitigating risks and promoting positive outcomes in high-risk pregnancy situations.
Question 3 of 5
A woman asks the nurse to recommend the best douche for use after menstruation. Which of the following responses by the nurse is appropriate?
Correct Answer: B
Rationale: The correct response, option B, "It is really best for women not to douche," is appropriate for several reasons. Douching is not recommended as it can disrupt the natural balance of bacteria in the vagina, leading to infections or other complications, especially in high-risk pregnancy situations. By advising against douching, the nurse promotes the maintenance of vaginal health and reduces the risk of potential harm to the woman and her developing fetus. Option A, suggesting tap water with white vinegar, is incorrect because the acidity of vinegar can disrupt the vaginal pH balance, leading to irritation or infection. Option C, stating that any over-the-counter douche is satisfactory, is incorrect as it promotes a practice that is generally discouraged. Option D is also incorrect as douching during menstruation can increase the risk of introducing bacteria into the uterus, potentially leading to infections or other complications. In an educational context, it is crucial for nurses to provide evidence-based recommendations to promote the health and well-being of pregnant women. Teaching about the potential risks of douching and emphasizing the importance of maintaining the natural vaginal flora can help prevent complications and support optimal pregnancy outcomes. Nurses play a key role in educating women about safe practices during pregnancy, including avoiding unnecessary interventions like douching.
Question 4 of 5
A nurse sees an overweight woman looking at the babies through the nursery window. The woman asks the nurse when the babies go to their mothers for feedings and about the location of the nearest stairwell. Which of the following replies by the nurse is most appropriate at this time?
Correct Answer: B
Rationale: The most appropriate response by the nurse in this situation is option B: "Please let me escort you to the mother’s room you are here to visit." This response is the best choice because it addresses the woman's inquiries directly and offers her assistance and guidance to the intended destination. Option A is incorrect because it provides vague information that may not address the woman's concerns effectively. Option C is incorrect as it inaccurately states that the babies are with their mothers for the majority of the day, which may not be the case in a hospital setting. Option D is also incorrect as it does not address the woman's questions and instead provides unrelated information about visitor preferences. In an educational context, it is essential for nurses to respond to patients and visitors with empathy, clear communication, and assistance when needed. This scenario highlights the importance of effective communication skills and providing support to individuals in healthcare settings, especially in high-stress situations such as a high-risk pregnancy unit.
Question 5 of 5
A male baby is born with scant amounts of vernix caseosa in his axillae and groin, scant amounts of lanugo on his shoulders, testes in his scrotum, and a strong suck. The nurse would estimate that the baby is which of the following gestational ages?
Correct Answer: D
Rationale: In this scenario, the correct answer is option D) 38 weeks gestational age. This baby is exhibiting characteristics that are typical of a full-term newborn. The presence of scant vernix caseosa and lanugo, descended testes, and strong sucking reflex are all indicative of a baby at around 38 weeks of gestation. Option A) 22 weeks is incorrect as a baby born at 22 weeks would not have these physical characteristics developed to the extent described in the scenario. Option B) 28 weeks is also incorrect as these features would not typically be present in a baby born at this gestational age. Option C) 32 weeks is incorrect as well since the described characteristics are more consistent with a baby closer to full term. Educationally, understanding the physical characteristics associated with different gestational ages is crucial for healthcare providers working with newborns, especially in high-risk pregnancy situations. Recognizing these signs can help determine appropriate care and interventions for newborns based on their gestational age.