Assessment of High Risk Pregnancy NCLEX Questions

Assessment of High Risk Pregnancy NCLEX Questions Related

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The nurse is caring for a 45-year-old client who is scheduled to have a chorionic villus sampling. Which information is most important for the nurse to obtain from the client before the procedure?

  • A. NPO status
  • B. Blood type and Rh
  • C. Weeks of gestation
  • D. Maternal bleeding disorders
Correct Answer: D

Rationale: The correct answer is D: Maternal bleeding disorders. This information is crucial before a chorionic villus sampling to assess the risk of excessive bleeding during the procedure due to potential clotting issues. Maternal bleeding disorders can increase the risk of complications during the procedure.

A: NPO status is not as critical for this procedure as it does not typically require fasting.
B: Blood type and Rh are important for other purposes but not specifically needed before a chorionic villus sampling.
C: Weeks of gestation is important for determining the timing of the procedure but does not directly impact the safety or success of the procedure.

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What patient symptom at 10 weeks of gestation requires further investigation by the nurse?

  • A. breast tenderness
  • B. infrequent nausea
  • C. change in appetite
  • D. weight loss
Correct Answer: D

Rationale: The correct answer is D: weight loss. At 10 weeks of gestation, weight loss is concerning as it may indicate potential issues like hyperemesis gravidarum or inadequate nutrition, posing risks to both the mother and fetus. Breast tenderness (A), infrequent nausea (B), and changes in appetite (C) are common symptoms during early pregnancy and may not necessarily indicate serious problems. Weight loss (D) should be investigated promptly to ensure the well-being of both the mother and the developing baby.

A 1-week-postpartum client calls her obstetrician’s office and states, 'I am a breastfeeding mother and my nipples are cracked and bleeding.' Which of the following comments by the nurse is appropriate at this time?

  • A. You will need to be seen by the doctor today.'
  • B. The blood will make the baby very sick. You should pump and dump your milk for at least 1 week.'
  • C. You are very high risk for infection. You should cleanse your nipples with dilute hydrogen peroxide twice every day.'
  • D. Lanolin cream applied after each feeding will help you to heal.'
Correct Answer: D

Rationale: Lanolin cream helps soothe and heal cracked nipples without harming the baby.

Which is the method of childbirth that helps prevent the fear-tension-pain cycle by using slow abdominal breathing in early labor and rapid chest breathing in advanced labor?

  • A. Bradley
  • B. Lamaze
  • C. Leboyer
  • D. Dick-Read
Correct Answer: D

Rationale: The correct answer is D: Dick-Read method. This method emphasizes relaxation and controlled breathing to reduce fear and pain during childbirth. Slow abdominal breathing in early labor helps maintain calmness, while rapid chest breathing in advanced labor assists in coping with intense contractions. The Dick-Read method's focus on the mind-body connection and natural childbirth aligns with preventing the fear-tension-pain cycle.

Summary:
A: Bradley method emphasizes partner-coached childbirth.
B: Lamaze method focuses on breathing techniques and relaxation.
C: Leboyer method emphasizes gentle birthing practices.

These choices do not specifically address the fear-tension-pain cycle with the same breathing techniques as the Dick-Read method.

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.

A 42-week-gestation neonate is being assessed. Which of the following findings would the nurse expect to see?

  • A. Folded and flat pinnae.
  • B. Smooth plantar surfaces.
  • C. Loose and peeling skin.
  • D. Short pliable fingernails.
Correct Answer: C

Rationale: Post-term neonates often have loose and peeling skin due to prolonged exposure to amniotic fluid.

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