Assessment of High Risk Pregnancy NCLEX Questions

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The nurse is completing the family assessment on a patient at 10 weeks of gestation. What data are included in the family assessment? Select all that apply.

  • A. annual income
  • B. total number of cousins
  • C. number of people living in the household
  • D. person in the household who makes the major decisions for the family
Correct Answer: A

Rationale: The correct answer is A: annual income. This data is crucial for assessing the family's financial resources and potential impact on the patient's health and well-being during pregnancy. Annual income can help identify possible financial stressors that may affect access to healthcare, nutrition, and overall prenatal care.

B: Total number of cousins is not typically part of a family assessment during pregnancy and does not directly impact the patient's prenatal care.

C: Number of people living in the household is important for understanding the household dynamics, but it may not be directly related to the patient's prenatal care needs.

D: Identifying the person in the household who makes major decisions is important for understanding family dynamics, but it may not directly impact the patient's prenatal care.

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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 triage nurse is interviewing a client, 19 years old, unmarried, who states, 'I felt a hard thing on the lip of my vagina this morning. It doesn’t hurt.' Which of the following questions is most important for the nurse to ask at this time?

  • A. Have any of your partners ever hurt you?'
  • B. Do you ever have unprotected intercourse?'
  • C. Have you ever had a baby?'
  • D. Do you think you may be pregnant?'
Correct Answer: B

Rationale: Unprotected intercourse increases the risk of sexually transmitted infections (STIs), which could explain the hard lump.

Which of the following features would the nurse expect to be absent in an 8-week-gestation embryo?

  • A. Four-chambered heart.
  • B. Fingers and toes.
  • C. Fully formed genitalia.
  • D. Facial features.
Correct Answer: C

Rationale: At 8 weeks, the embryo’s genitalia are not fully formed, though other features like the heart and facial structures are developing.

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.

At the first prenatal visit, the patient informs the nurse that the first day of her last menstrual period (LMP) was February 18, 2024. Using Naegle's Rule, calculate the patient's EDD.

  • A. 11-Nov-24
  • B. 11-Nov-25
  • C. 25-Nov-24
  • D. 25-Nov-25
Correct Answer: C

Rationale: The correct answer is C: 25-Nov-24. Naegle's Rule is to add 7 days to the first day of the last menstrual period (LMP), then subtract 3 months, and finally add 1 year. In this case, LMP was February 18, 2024. Adding 7 days gives February 25, 2024. Subtracting 3 months gives November 25, 2024. Adding 1 year gives the estimated due date (EDD) of November 25, 2024. Choices A, B, and D are incorrect because they do not follow the correct calculation steps of Naegle's Rule.

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