Assessment of High Risk Pregnancy NCLEX Questions

Assessment of High Risk Pregnancy NCLEX Questions Related

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The results of a contraction stress test (CST) are positive. Which intervention is necessary based on this test result?

  • A. Repeat the test in 1 week so that results can be trended based on this baseline result.
  • B. Contact the health care provider to discuss birth options for the patient.
  • C. Send the patient out for a meal and repeat the test to confirm that the results are valid.
  • D. Ask the patient to perform a fetal kick count assessment for the next 30 minutes and then reassess the patient.
Correct Answer: B

Rationale: The correct answer is B because a positive contraction stress test (CST) indicates potential fetal distress, requiring immediate medical attention. Contacting the health care provider is necessary to discuss birth options for the patient, such as potential induction or cesarean section to prevent harm to the fetus.

A is incorrect because waiting another week could pose risks to the fetus if distress is already present. C is incorrect as sending the patient out for a meal and repeating the test is not a valid or necessary intervention. D is incorrect as a fetal kick count assessment does not address the immediate concerns raised by a positive CST result.

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A fetus is in the LOA position in utero. Which of the following findings would the nurse observe when doing Leopold's maneuvers?

  • A. Hard, round object in the fundal region.
  • B. Flat object above the symphysis pubis.
  • C. Soft, round object on the left side of the uterus.
  • D. Small objects on the right side of the uterus.
Correct Answer: C

Rationale: In the LOA (left occiput anterior) position, the baby's back is on the left side of the uterus, which would feel like a soft, round object during Leopold's maneuvers.

A G1 P0000 gravida, whose labor was uneventful, delivered 1 minute ago. The baby’s Apgar score at this time is 3. Which of the following actions is appropriate for the nurse to make?

  • A. Administer ophthalmic prophylaxis.
  • B. Place the baby on the abdomen of the mother.
  • C. Obtain assistance for neonatal resuscitation.
  • D. Repeat the score to confirm its accuracy.
Correct Answer: C

Rationale: An Apgar score of 3 indicates the baby is in distress and requires immediate neonatal resuscitation.

The nurse is working with a pregnant woman who states that she is a vegan. Which of the following actions by the nurse is appropriate?

  • A. Advise the mother that she must eat some animal protein during her pregnancy.
  • B. Refer the woman to a nutritionist for diet counseling.
  • C. Remind the mother that cashews and coconut are excellent sources of calcium.
  • D. Congratulate the woman on agreeing to eat eggs and milk.
Correct Answer: B

Rationale: A nutritionist can help ensure the vegan mother receives adequate nutrients, such as B12, iron, and protein, during pregnancy.

On the third postpartum day a client tells the nurse that she feels sad and that she cries easily. The nurse should explain about which of the following?

  • A. These feelings are normal and should diminish when the baby is a week or so old.
  • B. The physician will likely order an antidepressant for the client to take at home.
  • C. If the client focuses on the fact that she has a healthy baby, the feelings will cease.
  • D. When the client is home with her family and friends, her sad feelings will disappear.
Correct Answer: A

Rationale: Postpartum blues are common and usually resolve within a week or two. Persistent sadness may indicate postpartum depression, but initial feelings are normal.

The nurse is caring for a baby whose blood type is A+ (positive) and direct Coombs’ test is + (positive), and whose mother’s blood type is O+ (positive). Which of the following nursing diagnoses is appropriate for this baby?

  • A. Risk for injury to the central nervous system.
  • B. Risk for fluid volume deficit.
  • C. Risk for interrupted family processes.
  • D. Risk for impaired parent-infant attachment.
Correct Answer: A

Rationale: A positive Coombs’ test indicates hemolytic disease of the newborn, which can lead to bilirubin buildup and potential central nervous system damage.

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