A labor and delivery nurse is orienting a newly hired nurse and is educating her on contraindications for vaginal exams. In which of the following scenarios is a vaginal exam contraindicated?
A client at 8 cm dilation and requesting to push
A client with vaginal bleeding and no complaints of abdominal pain
A client in latent labor with cervical dilation of 2 cm
A client with ruptured membranes and regular contractions
The Correct Answer is B
A. Vaginal exams are appropriate in this scenario. Assessing cervical dilation, effacement, fetal station, and position is critical at this stage of labor to determine whether the client is ready to begin pushing. Performing the exam helps guide safe labor management and supports maternal and fetal outcomes.
B. Vaginal exams are contraindicated in the presence of unexplained vaginal bleeding during pregnancy, particularly in the third trimester, because the bleeding could indicate placenta previa, vasa previa, or other serious placental issues. Performing a vaginal exam in such cases risks provoking severe hemorrhage, leading to maternal hypovolemic shock and fetal compromise. Before performing any vaginal examination, the cause of bleeding must be evaluated using non-invasive methods such as ultrasound, fetal monitoring, and laboratory studies. Even if the client is asymptomatic for pain, the risk of disrupting placental attachment makes vaginal exams unsafe.
C. Vaginal exams are safe and routine in latent labor. They help monitor cervical progression, effacement, and fetal position. Frequent exams may be limited to reduce infection risk, but there is no absolute contraindication in a low-risk latent labor client.
D. Vaginal exams are generally indicated after rupture of membranes to monitor labor progress. However, precautions must be taken to maintain aseptic technique and reduce the risk of infection (chorioamnionitis). Unless other contraindications exist (such as vaginal bleeding from placenta previa or signs of infection), the exam is considered safe and clinically necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Magnetic resonance imaging (MRI) can provide detailed images of breast tissue and is useful for evaluating the extent of disease, but it cannot definitively diagnose breast cancer. It is typically used as a supplemental tool after an abnormal mammogram or ultrasound.
B. Ultrasound is helpful in distinguishing between solid and cystic masses and guiding biopsies, but it cannot confirm malignancy on its own.
C. Core needle biopsy is the definitive diagnostic test for breast cancer. It involves obtaining a tissue sample from the suspicious area, which is then examined histologically to confirm the presence of malignant cells. This step is necessary before treatment planning.
D. Mammogram is a screening tool that detects abnormalities such as masses or microcalcifications, but it cannot confirm cancer. Abnormal findings on a mammogram require further diagnostic testing, such as a biopsy, for confirmation.
Correct Answer is D
Explanation
A. Emptying surgical drains is an important part of postoperative care and should be performed as instructed to prevent fluid accumulation and infection. This activity is safe and encouraged.
B. Progressive arm exercises are recommended to maintain shoulder mobility and prevent stiffness or lymphedema. These exercises should be done gradually according to the nurse’s instructions.
C. Lifting less than 2 lbs is safe and typically recommended early in the postoperative period to avoid strain on the surgical site.
D. Wearing clothing with tight sleeves on the operative side should be avoided because tight clothing can restrict circulation, increase swelling, and elevate the risk of lymphedema. Patients are advised to wear loose, comfortable clothing to support proper healing and reduce complications.
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