A nurse is inserting an indwelling urinary catheter for a male client.
Which of the following actions should the nurse take?

Lift the penis so that it is perpendicular to the client's body.

Cleanse the tip of the penis in a side-to-side motion.

Pick up the catheter 13 cm (5 in) from its tip.

Inflate the catheter balloon before insertion.

Answer and Explanation

The Correct Answer is A

The correct answer is choice A. Lift the penis so that it is perpendicular to the client’s body.

Choice A rationale:

Lifting the penis so that it is perpendicular to the client’s body straightens the urethra, making it easier to insert the catheter without causing trauma.

Choice B rationale:

While cleansing the tip of the penis in a circular motion is important for maintaining aseptic technique, it is not the specific action that facilitates the insertion of the catheter.

Choice C rationale:

Picking up the catheter 13 cm (5 in) from its tip is not a standard practice. The nurse should hold the catheter closer to the tip to maintain control and ensure accurate insertion.

Choice D rationale:

Inflating the catheter balloon before insertion can cause trauma to the urethra and is not recommended. The balloon should only be inflated once the catheter is correctly positioned in the bladder.

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Correct Answer is B

Explanation

Choice A rationale:

Moderate variability in the FHR is a reassuring sign of fetal well-being, indicating a responsive fetal autonomic nervous system to normal physiologic stimuli. It is considered a normal finding in active labor, suggesting that the fetus is well-oxygenated and able to cope with contractions.

Choice B rationale:

Prolonged decelerations are concerning patterns on the fetal heart rate (FHR) monitor, indicating potential fetal distress. Prolonged decelerations are defined as lasting more than 2 minutes but less than 10 minutes. These decelerations can be caused by umbilical cord compression, placental insufficiency, or maternal hypotension. Prompt intervention is required, making this choice the correct answer.

Choice C rationale:

Three uterine contractions within 10 minutes, also known as a contraction stress test (CST), is a normal finding. It assesses the fetal response to stress and is used to evaluate the placental function and fetal well-being.

Choice D rationale:

A baseline FHR of 115/min is within the normal range (110-160 beats per minute) for a term fetus. It indicates a stable fetal heart rate, and there is no immediate need for intervention.

A. "Tighten abdominal muscles to improve balance." B. "Bend at the waist when lifting objects from the floor." C. "Keep your feet together to provide a tight base of support." D. "Keep objects away from your center of gravity while lifting." .

Correct Answer is A

Explanation

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A nurse is inserting an indwelling urinary catheter for a male client.
Which of the following actions should the nurse take?