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A nurse is assisting with a pelvic examination of a client during their first prenatal visit. Which of the following actions should the nurse take?

A.

Ensure the client has a full bladder before the procedure.

B.

Instruct the client to bear down when the speculum is inserted.

C.

Encourage the client to take rapid, shallow breaths during the procedure.

D.

Apply povidone-iodine to the provider's fingers prior to bimanual examination.

Answer and Explanation

The Correct Answer is B

Choice A rationale

 

Ensuring the client has a full bladder before the procedure is incorrect. A full bladder can cause discomfort during the pelvic examination and may obscure the pelvic organs, making the examination more challenging for the provider.

 

Choice B rationale

 

Instructing the client to bear down when the speculum is inserted is correct. Bearing down helps relax the pelvic muscles, making it easier to insert the speculum and perform the examination with minimal discomfort.

 

Choice C rationale

 

Encouraging the client to take rapid, shallow breaths during the procedure is incorrect. This can increase anxiety and tension in the pelvic muscles, making the examination more uncomfortable.

 

Choice D rationale

 

Applying povidone-iodine to the provider's fingers prior to bimanual examination is incorrect. The standard procedure involves using gloves and lubricant to prevent infection and ensure patient comfort, not povidone-iodine.

 


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View Related questions

Correct Answer is A

Explanation

Choice A rationale

"You will be tested again for GBS at about 36 weeks of gestation.”. This is correct because retesting for GBS at 35-37 weeks of gestation is standard practice to identify colonization status before delivery, which helps in planning intrapartum antibiotic prophylaxis.

Choice B rationale

"If you test positive for GBS, the provider will need to perform a cesarean birth.”. This is incorrect because GBS colonization is not an indication for cesarean delivery. The primary intervention is antibiotic administration during labor to prevent neonatal infection.

Choice C rationale

"You will take an antibiotic during the last 2 weeks of pregnancy to avoid transferring GBS to your baby.”. This is incorrect because antibiotics are given intrapartum (during labor) to prevent GBS transmission, not during the last weeks of pregnancy.

Choice D rationale

"This infection can cause your baby to experience hearing loss at birth.”. This is incorrect because GBS infection primarily causes sepsis, pneumonia, and meningitis in neonates, not hearing loss.

Correct Answer is A

Explanation

Choice A rationale

Fundus located to the right of the umbilicus requires intervention. This can indicate a full bladder, which can inhibit uterine contraction and increase the risk of postpartum hemorrhage.

Choice B rationale

A temperature of 37.8° C (100° F) is a common finding postpartum and usually does not require intervention unless it is accompanied by other signs of infection.

Choice C rationale

Deep tendon reflexes 2+ is a normal finding and does not require intervention. It indicates normal neuromuscular function.

Choice D rationale

A moderate amount of lochia rubra is expected postpartum and does not require intervention unless it is excessive or associated with other abnormal symptoms.

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