Nokea
Before the pelvic examination, which intervention by the nurse is most appropriate?
- A. Give the client an enema.
- B. Instruct the client to urinate.
- C. Shave the client's perineum.
- D. Give the client a mild sedative.
Correct Answer: B
Rationale: Instructing the client to urinate ensures a comfortable examination by emptying the bladder, which can interfere with pelvic assessment.
You may also like to solve these questions
The nurse responds that, for clients with uncomplicated pregnancies, it is usually best to plan monthly visits for the first 28 weeks and then more frequent visits following which schedule?
- A. Weekly for the remainder of the pregnancy
- B. Every 2 weeks for the remainder of the pregnancy
- C. Every 2 weeks up to 36 weeks, then weekly for the last month
- D. Weekly up to 36 weeks, then twice weekly for the last month
Correct Answer: C
Rationale: Standard prenatal care involves monthly visits until 28 weeks, biweekly until 36 weeks, and weekly thereafter for uncomplicated pregnancies.
The delivery nurse is reporting to the postpartum nurse about the client who just delivered her first baby, a term newborn. Which number should the delivery nurse report for the client’s parity?
Correct Answer: 1
Rationale: The client has given birth to her first child; her parity is 1.
Multiple women are being seen in a clinic for various conditions. From which clients should the nurse prepare to obtain a group beta streptococcus (GBS) culture? Select all that apply.
- A. The client who is having symptoms of preterm labor
- B. The women who had a neonatal death 1 year ago
- C. All pregnant women coming to the clinic for care
- D. The women who had a spontaneous abortion 1 week ago
- E. The women who had an abortion for an unwanted pregnancy
Correct Answer: A,C
Rationale: The client in preterm labor should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. All pregnant women, regardless of risk status, should be screened for GBS infection. Between 10% and 30% of all women are colonized for GBS. There is no indication that the client with a previous neonatal death is pregnant. The client would not be screened for GBS solely because of a history of spontaneous abortion. The client would not be screened for GBS solely because of an elective abortion.
The nurse is counseling the client who is pregnant. The nurse should teach that which assessment finding requires follow-up with the HCP?
- A. Dependent edema
- B. Edema in the hands
- C. Generalized edema
- D. Edema occurring every evening
Correct Answer: C
Rationale: The nurse needs to teach the client that generalized edema is a sign of preeclampsia and requires follow-up by an HCP for further evaluation. Dependent edema is typical during pregnancy, resulting from relaxation of the blood vessels in the legs and decreased venous blood return. Edema in the hands is typical during pregnancy, particularly when a high-sodium diet is consumed. Edema that occurs every evening is a normal finding associated with decreased venous return and pelvic congestion from daily activity.
Twenty-four hours post—vaginal delivery, the postpartum client tells the nurse that she is concerned because she has not had a bowel movement (BM) since before delivery. Which action should be taken by the nurse?
- A. Document the data in the client’s health care records
- B. Notify the health care provider immediately
- C. Administer a laxative that has been prescribed pm
- D. Assess the client’s abdomen and bowel sounds
Correct Answer: A
Rationale: A spontaneous BM may not occur for 2 to 3 days after childbirth due to decreased muscle tone in the intestines during labor and the immediate postpartum period, possible prelabor diarrhea, and decreased food intake and dehydration during labor. Thus, documentation of the lack of a BM is the only action required. There is no need to notify the HCP for a normal finding. A laxative is unnecessary since a BM is not expected for 2 to 3 days postdelivery. Bowel sounds are not altered by a vaginal delivery, even though the passage of stool through the intestines is slowed.