Nursing Elites

1. 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.

2. A client, age 28, is 8 1/2 months pregnant. She is most likely to display which normal skin-color variation?

• A. vitiligo
• B. erythema
• C. cyanosis
• D. chloasma

Correct answer: D

Rationale: Chloasma, also known as the mask of pregnancy, is described as tan-to-brown patches on the face. This hyperpigmentation results from hormonal changes during pregnancy. Vitiligo is characterized by depigmented patches, erythema is redness of the skin due to increased blood flow, and cyanosis is a bluish discoloration due to poor circulation or lack of oxygen, none of which are typical skin-color variations during pregnancy. Therefore, in a pregnant client, the most likely normal skin-color variation to be displayed is chloasma.

3. The nurse is caring for a 4-year-old client. What is the most appropriate pain scale for the nurse to use during the assessment?

• A. McGill Pain Scale
• B. FLACC Pain Scale
• C. CRIES Pain Scale
• D. Wong-Baker Pain Scale

Correct answer: D

Rationale: The correct answer is the Wong-Baker Pain Scale. This scale is specifically designed for pediatric clients, including children as young as 3 years old, making it the most appropriate choice for a 4-year-old. It utilizes a simple visual scale with facial expressions that children can easily understand and use to express their pain levels. The FLACC and CRIES Pain Scales are also used for pediatric clients but are more focused on non-verbal cues and specific populations like infants or critically ill children. The McGill Pain Scale, on the other hand, is more complex and uses descriptive words, making it more suitable for adult clients who can better articulate their pain experiences.

4. An assessment of the skull of a normal 10-month-old baby should identify which of the following?

• A. closure of the posterior fontanel.
• B. closure of the anterior fontanel.
• C. overlap of cranial bones.
• D. ossification of the sutures.

Correct answer: B

Rationale: The correct answer is the closure of the anterior fontanel. By 10 months of age, the anterior fontanel should be closed. The posterior fontanel should actually close by the age of 2 months, making choice A incorrect. Overlap of cranial bones is not a typical finding in a normal 10-month-old baby's skull, so choice C is incorrect. Ossification of the sutures is an ongoing process in skull development and should not be a definitive indicator at this age, making choice D incorrect.

5. A nurse notes that a client's physical examination record states that the client's eyes moved normally through the six cardinal fields of gaze. The nurse interprets this to mean that which aspect of eye function is normal?

• A. Near vision
• B. Central vision
• C. Peripheral vision
• D. Ocular movements

Correct answer: D

Rationale: The correct answer is 'Ocular movements.' Moving the eyes through the six cardinal fields of gaze evaluates the function of the eye muscles, such as the medial rectus muscle, superior rectus muscle, superior oblique muscle, lateral rectus muscle, inferior rectus muscle, and inferior oblique muscle. Normal movement in these fields indicates proper ocular movements. Near vision is assessed using a handheld vision screener, central vision with a Snellen chart, and peripheral vision through the confrontation test. Therefore, the evaluation of ocular movements through the six cardinal fields of gaze specifically assesses this aspect of eye function. Choices A, B, and C are incorrect as they pertain to different aspects of vision function that are evaluated using distinct assessment methods, not through the six cardinal fields of gaze.

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