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Questions 149

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Question 1 of 5

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?

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.

Question 2 of 5

The school nurse is teaching a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates that further teaching is necessary?

Correct Answer: B

Rationale: vomiting contraindicated when child ingests hydrocarbons due to danger of aspiration

Question 3 of 5

A 10-year-old girl has been diagnosed with scabies. There are three other children and two adults living in the household. The nurse can best educate caregivers by stating,

Correct Answer: B

Rationale: Scabies is highly contagious via skin-to-skin contact or shared items. All household members should be treated simultaneously to prevent reinfestation, regardless of symptoms.

Question 4 of 5

The nursing assistant finds a client on the floor. Once the client is safe, which of the following should the nurse do next?

Correct Answer: B

Rationale: Falls require documentation in the medical record and an incident report to track safety issues and ensure follow-up.

Question 5 of 5

A client is being monitored using a central venous pressure monitor. If the pressure is 2 cm of water, the nurse should:

Correct Answer: B

Rationale: A CVP of 2 cm of water is low, suggesting hypovolemia; slowing the IV infusion prevents fluid overload while addressing the issue.

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