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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}
Explanation
High blood pressure during pregnancy can indicate preeclampsia, a potentially dangerous condition requiring prompt intervention. Headache is a common symptom associated with preeclampsia and can indicate worsening condition.
- Addressing blood pressure is crucial to prevent complications such as eclampsia or organ damage.
- Monitoring the headache is necessary because it may signal increased intracranial pressure or severe hypertension, both of which need immediate attention.
- Elevated liver enzymes (AST 200 units/L) indicate potential liver involvement, a severe aspect of preeclampsia known as HELLP syndrome.
- Keeping a close eye on liver enzymes helps in assessing the progression and severity of preeclampsia and potential liver damage.
Heart rate and respiratory rate are within normal ranges, so they are less immediately concerning. Oxygen saturation is also normal, indicating adequate oxygenation. The headache and elevated liver enzymes are more urgent indicators of severe preeclampsia complications.
Correct Answer is C
Explanation
Choice A rationale
A weak cry is not a typical manifestation of neonatal abstinence syndrome (NAS). NAS usually presents with a high-pitched, persistent cry due to central nervous system irritability.
Choice B rationale
Decreased muscle tone is not common in NAS. Infants with NAS often exhibit hypertonia, characterized by increased muscle tone and rigidity.
Choice C rationale
This statement is correct because an exaggerated Moro reflex is a common sign of NAS, indicating central nervous system hyperactivity in response to withdrawal from maternal drugs.
Choice D rationale
An infant with NAS does not console easily. They are often difficult to soothe due to irritability and discomfort from withdrawal symptoms. .
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