High Risk Perinatal NCLEX Questions

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Estefany_Pujols Preview NUR20 14 terms sup The home care nurse visits a pregnant client who has a diagnosis of mild preeclampsia. Which assessment finding indicates worsening of the preeclampsia and the need to notify the HCP?

• Urinary output increases
• Dependent edema resolves
• BP is at prenatal baseline
• Client complains of blurred vision and headache
• Client complains of blurred vision and headache

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with severe preeclampsia.The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

• Enlargement of the breasts
• Complaints of feeling hot when the room is cold
• Periods of fetal movement followed by quiet periods
• Bleeding in the gums, petechiae, and purpura
• Bleeding in the gums, petechiae, and purpura

The nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which statement made by the client indicates a need for further teaching?

• "I should stay on the diabetic diet"
• "I should perform glucose monitoring at home"
• "I should avoid exercise because of the negative

effects on insulin production"

• "I should report signs of infection immediately to my

health care provider"

• "I should avoid exercise because of the negative effects on insulin production"

The nurse in a maternity unit is reviewing the client's records. Which client would the nurse identify as being at the most risk for developing disseminated intravascular coagulation?

• A primigravida with mild preeclampsia
• A primigravida who delivered a 10-lb infant 3 hours ago
• A gravida 2 who has just been diagnosed with dead

fetus syndrome

• A gravida 4 who delivered 8 hours ago and has lost

500mL of blood

• A gravida 2 who has just been diagnosed with dead fetus syndrome

The home care nurse is monitoring a pregnant client with gestational hypertension who is at risk for preeclampsia.At each home care visit, the nurse assesses the client for which classic signs of preeclampsia? SATA

• Proteinuria
• Hypertension
• Low-grade fever
• Generalized edema
• Increased pulse rate
• Increased respiratory rate
• Proteinuria
• Hypertension
• Generalized edema

Edema is a classic sign, but no longer diagnostic criteria for preeclampsia.The nurse is assessing a pregnant client with type 1 diabetes mellitus about her understanding regarding changing insulin needs during pregnancy. The nurse determines that further is needed if the client makes which statement?

• "I will need to increase my insulin dosage during the

first 3 months of pregnancy"

• "My insulin dose will likely need to be increased during

the second and third trimesters"

• "Episodes of hypoglycemia are more likely to occur

during the first 3 months of pregnancy"

• "My insulin needs should return to normal within 7-10

days after birth if I am bottle-feeding"

• "I will need to increase my insulin dosage during the first 3 months of

pregnancy" A pregnant client reports to a health care clinic, complaining of loss of appetite, weight loss, and fatigue.After assessment of the client, tuberculosis is suspected.A sputum culture is obtained and identifies Mycobacterium tuberculosis. Which instruction should the nurse include in the client's teaching plan?

• Therapeutic abortion is required
• She will have to stay at home until treatment is

completed

• Medication will not be started until after delivery of the

fetus

• Isoniazid plus rifampin will be required for 9 months
• Isoniazid plus rifampin will be required for 9 months

The nurse is providing instruction to a maternity client with a history of cardiac disease regarding appropriate dietary measures. Which statement, if made by the client, indicates an understanding of the information provided by the nurses.

• "I should increase my sodium intake during pregnancy"
• "I should lower my blood volume by limiting my fluids"
• "I should maintain a low-calorie diet to prevent any

weight-gain"

• "I should drink adequate fluids fluids and increase my

intake of high-fiber foods" The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the health care provider's prescriptions and should question which prescription?

• Prepare the client for an ultrasound
• Obtain equipment for a manual pelvic examination
• Prepare to draw a hemoglobin and hematocrit blood

sample

• Obtain equipment for external electronic fetal heart

rate monitoring

• Obtain equipment for a manual pelvic examination

The nurse is providing instruction to a pregnant client with a human immunodeficiency virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the feeding options that are available. Which responses should the nurse make to the client?

• "You will need to bottle feed your newborn"
• "You will need to feed your newborn by NG feeding
• "You will be able to breast feed for 6 months and then

will need to switch to bottle-feeding"

• "You will be able to breast feed for 9 months and then

will need to switch to bottle-feeding"

• "You will need to bottle feed your newborn"

The nurse is performing an initial assessment on a client who has just been told that a pregnancy test is positive.Which assessment finding indicates that the client is at risk for preterm labor?

• The client is a 35 yo primigravida
• The client has a history of cardiac disease
• The client's hgb is 13.5
• The client is a 20 yo primigravida of average weight

and height

• The client has a history of cardiac disease

The nurse is performing an assessment on a client diagnosed with placenta previa. Which of these assessment finding would the nurse expect to note?

SATA

• Uterine rigidity
• Uterine tenderness
• Severe abdominal pain
• Bright red abdominal bleeding
• Soft, relaxed nontender bleeding
• Fundal height may be greater than expected for

gestational age

• Bright red abdominal bleeding
• Soft, relaxed nontender bleeding
• Fundal height may be greater than expected for gestational age (+/-)

The nurse administers erythromycin ointment 0.5% to the eyes of a newborn and the mother asks the nurse why is is performed. Which explanation is best for the nurse t provide about the neonatal eye prophylaxis?

• Protects the newborn's eyes from possible infection

acquired while hospitalized

• Prevents cataracts in the newborn born to a woman

susceptible to rubella

• Minimizes the spread of microorganisms to the

newborn from invasive procedures during labor

• Prevents an infection from occurring after delivery in a

newborn born to a woman with an untreated gonococcal infection

• Prevents an infection from occurring after delivery in a newborn born to a

woman with an untreated gonococcal infection The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome?

• Tachypnea and retractions
• Acrocyanosis and grunting
• Hypotension and bradycardia
• Presence of a barrel chest and acrocyanosis
• Tachypnea and retractions