Nursing Elites

1. When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours?

• A. nausea and vomiting
• B. itching
• C. urinary retention
• D. somnolence

Correct answer: B

Rationale: A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting up to 10 hours. Nausea and vomiting might occur 4-7 hours after injection. While urinary retention is a side effect of postpartum epidural morphine, it is not typically assessed within the first 3 hours. Somnolence is a rare side effect and not commonly observed within the first 3 hours. Therefore, itching is the most likely side effect to be observed within the initial 3 hours after administering postpartum epidural morphine.

2. 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.

3. A Mexican American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands which primary purpose of including cultural information in the health assessment?

• A. Confirm the medical diagnosis.
• B. Make accurate nursing diagnoses.
• C. Identify any hereditary traits related to the epilepsy.
• D. Determine what the client believes has caused the epilepsy.

Correct answer: D

Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican American culture, epilepsy is seen as a reflection of physical imbalance. While gathering data on hereditary traits and formulating nursing diagnoses are important, they are not the primary reasons for including cultural information in the health assessment. It is crucial to understand the client's beliefs as they may impact their perceptions of health, treatment adherence, and overall care. It is not the nurse's role to confirm a medical diagnosis, as this is the responsibility of the healthcare provider.

4. When determining a fetal heart rate (FHR) and noting accelerations from the baseline rate when the fetus is moving, a nurse interprets this finding as:

• A. A reassuring sign
• B. An indication of the need to contact the physician
• C. An indication of fetal distress
• D. A nonreassuring sign

Correct answer: A

Rationale: When a nurse notes accelerations from the baseline rate of the fetal heart rate, particularly when they occur with fetal movement, it is considered a reassuring sign. This indicates a healthy response to fetal activity. Reassuring signs in FHR monitoring include an average rate between 120 and 160 beats/min at term, a regular rhythm with slight fluctuations, accelerations from the baseline rate (often associated with fetal movement), and the absence of decreases from the baseline rate. Choices B, C, and D are incorrect because accelerations in FHR with fetal movement are not indicative of the need to contact the physician, fetal distress, or a nonreassuring sign. These signs would typically be associated with other abnormal FHR patterns that would warrant further assessment and intervention.

5. 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.

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