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 assisting with data collection uses the back of the hand to feel the client's skin on both arms and notes that the skin is warm. The nurse makes which determination?

• A. The client has a fever.
• B. The skin temperature is normal.
• C. The client needs to drink additional fluids.
• D. The client needs to have the blanket removed.

Correct answer: B

Rationale: To assess skin temperature, the nurse would first note the temperature of their own hands. Then, using the backs of the hands to palpate the client's skin bilaterally, warmth suggests normal circulatory status if the skin is warm and the temperature is equal bilaterally. The hands and feet may feel slightly cooler in a cool environment. Options A, C, and D are incorrect responses. A warm skin temperature does not indicate a fever, the need for additional fluids, or the need to have the blanket removed.

3. The nurse is assessing an 18-month-old. Which of these statements made by the parent or caregiver would require follow-up?

• A. I'm worried that my child is not using two-word phrases yet.
• B. My child has recently taken a few steps but does not seem stable when standing.
• C. My child seems to have developed separation anxiety when I leave.
• D. I'm letting my child use a spoon to eat.

Correct answer: B

Rationale: The correct answer is 'My child has recently taken a few steps but does not seem stable when standing.' By 18 months of age, children should have taken their first steps and stand well. If a child hasn't made progress by this age, a physical therapy evaluation may be necessary. It is normal for an 18-month-old to start using a spoon to eat. However, the use of two-word phrases is not typically expected until 2 years of age. Separation anxiety is a common developmental phase that typically occurs between 6 and 18 months, so it does not require immediate follow-up. Therefore, the statement about the child not being stable when standing raises a red flag and necessitates further evaluation.

4. When a 16-year-old girl visits the women's health clinic to obtain information about birth control because she is sexually active and wants to avoid pregnancy, what should the nurse do first when interviewing the client?

• A. Assess the client's knowledge of available birth control methods.
• B. Inform the client that birth control methods can be discussed without the client's boyfriend present.
• C. Tell the client that for her age and lifestyle, birth control pills would be one of the methods of contraception.
• D. Give the client written material about various birth control methods and ask her to read them and to call if she has any questions.

Correct answer: A

Rationale: When a client seeks information about birth control, it is essential for the nurse to first assess the client's existing knowledge on the subject. This enables the nurse to provide tailored information that complements what the client already knows, facilitating better understanding and decision-making. Providing written material is a helpful educational tool but should not be the first intervention. Offering specific advice on birth control methods based on age and lifestyle limits the client's autonomy and decision-making process. Mentioning the client's boyfriend as a requirement for discussing birth control is inappropriate and nontherapeutic, as the client should be able to seek information independently.

5. Which of the following is least appropriate when caring for a stable postpartum client?

• A. Assess the location and height of the fundus.
• B. Conduct a family assessment, including the mother's future plans for returning to work, if applicable.
• C. Monitor the client for bleeding.
• D. Provide perineal care.

Correct answer: D

Rationale: Providing perineal care is not the least appropriate when caring for a stable postpartum client. Perineal care is essential for maintaining hygiene and preventing infection after delivery. Assessing the location and height of the fundus helps in monitoring postpartum uterine involution, which is crucial for assessing the recovery progress. Conducting a family assessment, including the mother's future plans for returning to work, is important for understanding the support system available for the mother during the postpartum period. Monitoring the client for bleeding is critical to promptly identify and address any postpartum hemorrhage. Therefore, providing perineal care is the least appropriate option among the choices provided as it is a fundamental aspect of postpartum care.

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