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?
Ensure the client has a full bladder before the procedure.
Instruct the client to bear down when the speculum is inserted.
Encourage the client to take rapid, shallow breaths during the procedure.
Apply povidone-iodine to the provider's fingers prior to bimanual examination.
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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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.