Assessment of High Risk Pregnancy NCLEX Questions

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The nurse is discussing the purpose of the physical examination with a patient at the first prenatal visit. What information does the nurse include in the discussion?

  • A. The physical exam helps to confirm the patient's current health.
  • B. The physical exam determines nutritional risk factors.
  • C. The physical exam confirms the diagnosis of STIs.
  • D. The physical exam includes urinalysis.
Correct Answer: A

Rationale: The correct answer is A because the physical exam at the first prenatal visit aims to confirm the patient's current health status, assess baseline health indicators, and identify any potential risks or issues that may affect the pregnancy. This information is crucial for developing a personalized care plan for the patient and ensuring a healthy pregnancy outcome.

Choice B is incorrect because determining nutritional risk factors typically involves assessing dietary habits, weight, and specific nutrient deficiencies, which are not solely addressed through a physical exam.

Choice C is incorrect as confirming the diagnosis of STIs would require specific testing and not solely rely on a physical examination.

Choice D is incorrect because while urinalysis may be part of the physical exam, its primary purpose is not solely to include urinalysis but to comprehensively evaluate the patient's overall health.

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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?

  • A. 31 cm
  • B. 33 cm
  • C. 37 cm
  • D. 38 cm
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.

A school nurse is discussing the male reproductive system with the students in a high school health class. Which of the following information about the hormone testosterone should be included in the discussion?

  • A. Testosterone is what makes boys more muscular than girls.'
  • B. The level of testosterone in boys changes every month like female hormones do.'
  • C. Testosterone is produced by the male prostate gland.'
  • D. The production of testosterone usually stops by the time a man is fifty years old.'
Correct Answer: A

Rationale: Testosterone is responsible for the development of male secondary sexual characteristics, including increased muscle mass.

A nurse has just received report on 4 neonates in the newborn nursery. Which of the babies should the nurse assess first?

  • A. Neonate whose mother is HIV positive.
  • B. Neonate whose mother is group B streptococcus positive.
  • C. Neonate whose mother’s labor was 12 hours long.
  • D. Neonate whose mother gained 45 pounds during her pregnancy.
Correct Answer: B

Rationale: The neonate whose mother is group B streptococcus positive should be assessed first due to the risk of early-onset sepsis.

Which technique would provide the best pain relief for a pregnant woman with an occiput posterior position?

  • A. Neuromuscular disassociation
  • B. Effleurage
  • C. Psychoprophylaxis
  • D. Sacral pressure
Correct Answer: D

Rationale: The correct answer is D: Sacral pressure. This technique involves applying pressure to the sacrum to alleviate back pain associated with an occiput posterior position. The pressure helps relieve tension and discomfort in the lower back, providing effective pain relief for the pregnant woman.

A: Neuromuscular disassociation is not specific to addressing the pain associated with the occiput posterior position in pregnancy.
B: Effleurage is a gentle massage technique that may provide some relaxation but may not be as effective as sacral pressure for pain relief in this specific scenario.
C: Psychoprophylaxis is a method of preparing for childbirth through education and relaxation techniques, but it may not directly target the pain caused by the occiput posterior position.

In summary, sacral pressure is the most appropriate technique as it directly addresses the specific pain associated with the occiput posterior position in pregnancy, unlike the other choices.

A breastfeeding client, 6 days postdelivery, calls the postpartum unit stating, “I think I am engorged. My breasts are very hard and hot and they really hurt.” Which of the following questions should the nurse ask at this time?

  • A. “Have you taken a warm shower this morning?”
  • B. “Do you have an electric breast pump?”
  • C. “How much did you have to drink yesterday?”
  • D. “When was the last time you fed the baby?”
Correct Answer: D

Rationale: Asking when the client last fed the baby helps determine if engorgement is due to infrequent feeding, which is a common cause of breast engorgement.

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