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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

This finding indicates fetal distress. Recurrent variable decelerations in the fetal heart rate (FHR) can be a sign of umbilical cord compression, which can compromise fetal oxygenation.

Choice B rationale

Uterine contractions every 6 minutes are within the normal range for the latent phase of labor and do not indicate fetal risk.

Choice C rationale

Moderate variability of the FHR is a reassuring sign and suggests that the fetus is well-oxygenated and neurologically intact.

Choice D rationale

Uterine contractions lasting 30 to 45 seconds are typical for the latent phase of labor and do not indicate fetal distress.

Correct Answer is B

Explanation

Choice A rationale

Chemotherapy is not a standard treatment for a molar pregnancy unless malignancy is suspected or confirmed. It is usually monitored with regular HCG levels and follow-up.

Choice B rationale

Attending a support group is crucial for emotional support and ensuring that the client has access to resources and information about recovery and future pregnancy planning.

Choice C rationale

Home palliative services are not typically required after a molar pregnancy unless there are specific complications that necessitate such care. The focus is generally on monitoring HCG levels and follow-up.

Choice D rationale

An amniocentesis is not needed after a molar pregnancy. Follow-up includes HCG level monitoring to ensure all molar tissue is gone and to watch for malignancy, not amniocentesis.

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