Assessment of High Risk Pregnancy NCLEX Questions

Assessment of High Risk Pregnancy NCLEX Questions Related

Review Assessment of High Risk Pregnancy NCLEX Questions related questions and content

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?

  • A. Since you are already bleeding, we cannot guarantee that the ultrasound will not have any negative effects on your pregnancy.'
  • B. Ultrasounds use sound waves to view your baby, not radiation, so the procedure will not harm your baby.'
  • C. There are no guarantees when you have a procedure performed.'
  • D. The doctor wouldn't try to order a test that would hurt your baby.'
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.

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A patient with an IUD in place has a positive pregnancy test. When planning care, the nurse will base decisions on which anticipated action?

  • A. A therapeutic abortion will need to be scheduled since fetal damage is inevitable.
  • B. Hormonal analyses will be done to determine the underlying cause of the false-positive test result.
  • C. The IUD will need to be removed to avoid complications such as miscarriage or infection.
  • D. The IUD will need to remain in place to avoid injuring the fetus.
Correct Answer: C

Rationale: Rationale:
C is correct because when a patient with an IUD in place has a positive pregnancy test, the IUD should be removed to avoid complications such as ectopic pregnancy, miscarriage, or infection. Leaving the IUD in place can increase the risk of adverse outcomes for both the mother and the fetus. Removing the IUD allows for safer management of the pregnancy and reduces potential harm.

Summary:
A: Incorrect. Fetal damage is not inevitable, and a therapeutic abortion is not the immediate action required in this situation.
B: Incorrect. Hormonal analyses are not the priority when a positive pregnancy test with an IUD in place is detected.
D: Incorrect. Leaving the IUD in place can lead to complications and is not the recommended course of action.

What point in the pregnancy is the most accurate time to determine gestational age through ultrasound?

  • A. First trimester
  • B. Second trimester
  • C. Third trimester
  • D. No difference in accuracy among the trimesters
Correct Answer: A

Rationale: The correct answer is A: First trimester. During the first trimester, gestational age can be accurately determined through ultrasound by measuring the crown-rump length of the fetus. This measurement is most accurate during this time as the fetus is small and growth is consistent. In the second and third trimesters, other factors such as fetal growth variations and positioning can affect the accuracy of gestational age determination. Therefore, the first trimester is the most accurate time for determining gestational age through ultrasound. Other choices are incorrect because the precision of ultrasound measurements decreases as pregnancy progresses, making the first trimester the optimal window for accurate gestational age assessment.

What is the term for a nonstress test in which there are two or more fetal heart rate accelerations of 15 or more beats per minute (BPM) with fetal movement in a 20-minute period?

  • A. Positive
  • B. Negative
  • C. Reactive
  • D. Nonreactive
Correct Answer: C

Rationale: The correct answer is C: Reactive. In a nonstress test, a reactive result is considered normal and indicates a healthy fetus. This is because it shows two or more fetal heart rate accelerations of 15 or more BPM with fetal movement in a 20-minute period, which signifies a responsive and healthy fetal heart rate pattern. The other choices are incorrect because:
A: Positive typically indicates a concerning result in medical contexts.
B: Negative signifies an abnormal result in this context.
D: Nonreactive suggests a lack of desired fetal heart rate accelerations with movement, which is not ideal.

A nurse is completing a minimum data set. Which area is the nurse working?

  • A. Nursing center
  • B. Psychiatric facility
  • C. Rehabilitation center
  • D. Adult day care center
Correct Answer: A

Rationale: Nurses who work in a nursing center (nursing home or nursing facility) are required to complete a minimum data set on each patient. Minimum data set is not needed for psychiatric, rehabilitation, or adult day care centers.

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.

  • A. Have you experienced any recent vaginal bleeding?
  • B. Have you experienced any recent vaginal discharge?
  • C. How many weeks pregnant are you?
  • D. When was the last time you felt the baby move?
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.

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