Nokea
During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?
- A. Right breech presentation
- B. Right occipital anterior presentation
- C. Left sacral anterior presentation
- D. Left occipital transverse presentation
Correct Answer: A
Rationale: Fetal heart tones loudest in the upper-right quadrant suggest a breech presentation, with the fetus's heart higher in the uterus.
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Which early morning activity helps to reduce the symptoms associated with rheumatoid arthritis?
- A. Brushing the teeth
- B. Drinking a glass of juice
- C. Holding a cup of coffee
- D. Brushing the hair
Correct Answer: C
Rationale: Holding a warm cup of coffee can reduce morning stiffness in rheumatoid arthritis by providing warmth and gentle joint movement.
The nurse is caring for a client post-myocardial infarction on the cardiac unit. The client is exhibiting symptoms of shock. Which clinical manifestation is the best indicator that the shock is cardiogenic rather than anaphylactic?
- A. BP 90/60
- B. Chest pain
- C. Anxiety
- D. Temp 98.6°F
Correct Answer: B
Rationale: Chest pain is a hallmark of cardiogenic shock due to myocardial infarction, reflecting cardiac ischemia. Anaphylactic shock typically involves allergic symptoms like urticaria or bronchospasm. Low BP, anxiety, and normal temperature are nonspecific.
A teenage client tells the nurse about her plans to be a lifeguard this summer. The nurse would be concerned if she saw the client was taking which medication? Select all that apply.
- A. tetrahydrozoline (Tetryzoline)
- B. isotretinoin (Accutane)
- C. levonorgestrel (Levora)
- D. sulfamethoxazole (Bactrim)
Correct Answer: B
Rationale: Isotretinoin (Accutane) causes photosensitivity, increasing sunburn risk, which is concerning for a lifeguard exposed to sunlight. Other medications do not pose significant outdoor risks.
The nurse is assessing a newborn in the well-baby nursery. Which finding should alert the nurse to the possibility of a cardiac anomaly?
- A. Diminished femoral pulses
- B. Harlequin's sign
- C. Circumoral pallor
- D. Acrocyanosis
Correct Answer: A
Rationale: Diminished femoral pulses suggest coarctation of the aorta, a cardiac anomaly, requiring further evaluation.
A 78-year-old client with a history of diabetes mellitus type 2, GERD, and hypertension is hospitalized with pneumonia and rings the call bell at 11 PM, complaining of being unable to sleep and having 'indigestion' and 'heartburn.' Which of the following initial interventions is most indicated?
- A. Administer antacid per prn order.
- B. Administer acetaminophen per prn order.
- C. Administer hypnotic per prn order.
- D. Assess cardiac and respiratory status.
Correct Answer: D
Rationale: In an elderly client with comorbidities, indigestion and heartburn may indicate a cardiac event, so assessing cardiac and respiratory status (D) is the priority. Administering medications (A, B, C) is secondary.