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
Positioning the newborn's car seat at a 45° angle helps to maintain an open airway and reduces the risk of the baby's head falling forward, which can obstruct breathing.
Choice B rationale
Placing the car seat in a forward-facing position is incorrect for a newborn. Newborns and infants should always be placed in a rear-facing car seat to protect their head, neck, and spine in the event of a crash.
Choice C rationale
Placing a rolled blanket behind the newborn's neck is not recommended as it can alter the position of the head and neck, potentially compromising the airway. Proper positioning is crucial to ensure safety and comfort.
Choice D rationale
The retainer clip should be positioned at the level of the newborn's armpits, not the umbilicus. Proper placement of the retainer clip ensures that the harness is secure and reduces the risk of injury in a collision.
Correct Answer is B
Explanation
Choice A rationale
Elevating the client's legs is incorrect as an initial intervention. It is more important to address the potential cause of the late decelerations first.
Choice B rationale
Turning the client onto their side is correct. This intervention can improve blood flow to the fetus and reduce the pressure on the vena cava, potentially alleviating late decelerations.
Choice C rationale
Palpating the client's uterus is not the first action. It is essential to address maternal positioning and oxygenation issues first.
Choice D rationale
Increasing the client's IV fluid infusion rate may help, but it is not the initial action. Positioning changes can have an immediate effect on fetal oxygenation.