A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain.
The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as:

Choice A rationale

Delayed documentation increases the risk of medication errors, as details about administration, patient response, and specific timing can be forgotten or inaccurately recalled, compromising patient safety and the accuracy of the medical record.

Choice B rationale

Nurses are legally and professionally obligated to document medications they personally administer. Documentation by a pharmacy technician is inappropriate and violates the principle of direct accountability for medication administration.

Choice C rationale

Only the individual who directly administers the medication should document its administration. This ensures accuracy, accountability, and traceability of the medication process, preventing errors and maintaining legal integrity of the medical record.

Choice D rationale

Immediate documentation after medication administration is a critical safety principle. It accurately reflects the precise time of administration, allowing for timely assessment of patient response, identification of adverse effects, and continuity of care.

Choice A rationale

Asking the client to stick out their tongue and move it from side to side, then up and down, directly assesses the function of the hypoglossal nerve (cranial nerve XII). This nerve innervates the intrinsic and extrinsic muscles of the tongue, controlling its movement, which is essential for speech and swallowing, thereby evaluating its motor integrity.

Choice B rationale

Asking the client to stick out their tongue primarily assesses general tongue protrusion, but does not provide as comprehensive an assessment of hypoglossal nerve function as evaluating its full range of motion. Unilateral weakness or deviation, which is indicative of nerve damage, is better observed with side-to-side and up-and-down movements.

Choice C rationale

Asking the client to cover one eye and read a note card assesses visual acuity and the function of the optic nerve (cranial nerve II). This technique evaluates the eye's ability to perceive details and is unrelated to the motor function of the tongue or the hypoglossal nerve.

Choice D rationale

Having the patient smile, frown, and puff their cheeks primarily assesses the facial nerve (cranial nerve VII). This nerve controls the muscles of facial expression, including those involved in smiling, frowning, and puffing out the cheeks, and is distinct from the hypoglossal nerve's role in tongue movement.