Nursing Elites

1. A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if the mother performs which action?

• A. Uses a cotton-tipped swab to carefully clean inside the infant's nose
• B. Uncovers only the body part being washed
• C. Washes the diaper area first
• D. Washes the infant's chest first

Correct answer: B

Rationale: When bathing a newborn, it is crucial to follow a specific sequence for thorough cleaning and safety. The correct sequence includes starting with the eyes and face, then moving to the external ear, areas behind the ears, neck, hands, arms, legs, and finally the diaper area. Keeping the infant warm is essential, so only the body part being washed should be uncovered. Using a cotton-tipped swab to clean inside the infant's nose is not recommended due to the risk of injury if the infant moves suddenly. Washing the diaper area first is incorrect as it should be done towards the end of the bath to prevent contamination. Washing the infant's chest first is also incorrect as it deviates from the recommended bathing sequence for a newborn.

2. If a client has chronic renal failure, which of the following sexual complications is the client at risk of developing?

• A. retrograde ejaculation
• B. decreased plasma testosterone
• C. hypertrophy of testicles
• D. state of euphoria

Correct answer: B

Rationale: In chronic renal failure, untreated, the client is at risk of developing decreased plasma testosterone. This condition leads to atrophy of the testicles and decreased spermatogenesis. Retrograde ejaculation is not a complication of chronic renal failure but can occur after transurethral resection of the prostate. The testicles atrophy in chronic renal failure; they do not hypertrophy. Additionally, chronic renal failure often leads to a state of depression, not euphoria.

3. A woman is receiving oxytocin to induce labor. Which action should the nurse take first upon noting the presence of late decelerations on the fetal heart rate (FHR) monitor?

• A. Notifying the healthcare provider
• B. Stopping the oxytocin infusion
• C. Checking the woman's blood pressure and pulse
• D. Increasing the intravenous (IV) rate of the nonadditive solution

Correct answer: B

Rationale: When late decelerations are noted on the fetal heart rate (FHR) monitor during oxytocin infusion, it indicates decreased oxygenation to the fetus. The immediate action the nurse should take is to stop the oxytocin infusion. This helps reduce uterine activity, increase fetal oxygenation, and prevent further stress on the fetus. Stopping the oxytocin infusion is crucial to address the underlying issue causing the late decelerations. Checking the woman's blood pressure and pulse, increasing the IV rate of the nonadditive solution, or notifying the healthcare provider can be important actions but are secondary to stopping the oxytocin infusion in this scenario.

4. According to Erik Erikson's developmental theory, which choice is a developmental task of the middle adult?

• A. Redefining self-perception and capacity for intimacy
• B. Making decisions concerning career, marriage, and parenthood
• C. Providing guidance during interactions with his children
• D. Verbalizing readiness to assume parental responsibilities

Correct answer: C

Rationale: According to Erikson's developmental theory, the primary developmental task of the middle adult is to achieve generativity. Generativity is the willingness to care for and guide others. Middle adults can achieve generativity with their own children or the children of close friends or through guidance in social interactions with the next generation. Providing guidance during interactions with his children aligns with this developmental task. Choices A, B, and D are not specific to the middle adult stage as they are tasks associated with young adults. Redefining self-perception and capacity for intimacy, making decisions concerning career, marriage, and parenthood, and verbalizing readiness to assume parental responsibilities are all developmental tasks of the young adult according to Erikson's theory.

5. While assisting with data collection, the nurse asks the client to close their jaws tightly. Subsequently, the nurse tries to open the closed jaws. In this technique, the nurse is assessing the motor function of which nerve?

• A. Trochlear nerve
• B. Abducens nerve
• C. Trigeminal nerve
• D. Oculomotor nerve

Correct answer: C

Rationale: The correct answer is C: Trigeminal nerve. To test the motor function of the trigeminal nerve (cranial nerve V), the nurse assesses the muscles of mastication by asking the client to clench their teeth. By trying to separate the client's jaws, the nurse evaluates the strength of the temporal and masseter muscles innervated by the trigeminal nerve. This technique helps assess if the trigeminal nerve is functioning properly. Choices A, B, and D are incorrect because they relate to other cranial nerves that are not involved in the specific motor function being tested in this scenario. These nerves are usually assessed through different examinations such as assessing the pupils and extraocular movements, which are not part of the jaw clenching and opening technique described in the question.

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