A nurse is reviewing the physical exam findings of a woman who has come to the clinic with reports of feeling a dragging sensation in her vagina. The exam reveals the posterior bladder wall protruding into the anterior vaginal wall. The nurse interprets this finding as indicative of which condition?
uterine prolapse
enterocele
cystocele
rectocele
The Correct Answer is C
A. Uterine prolapse: Uterine prolapse occurs when the uterus descends into or outside the vaginal canal due to weakened pelvic support. It presents with a sensation of pelvic pressure or a visible bulge but does not involve the bladder wall protruding into the vagina.
B. Enterocele: An enterocele involves herniation of the small intestine and peritoneal sac into the vaginal wall, usually between the uterus and rectum. It typically occurs after hysterectomy and causes a feeling of pelvic pressure rather than a bladder protrusion.
C. Cystocele: A cystocele results from the weakening of the anterior vaginal wall, allowing the bladder to bulge into the vaginal canal. Symptoms include a dragging or pressure sensation in the vagina, urinary frequency, incontinence, and incomplete bladder emptying.
D. Rectocele: A rectocele occurs when the rectal wall protrudes into the posterior vaginal wall due to weakened pelvic muscles. It is usually associated with constipation, straining, and a sensation of rectal fullness, not anterior bladder wall bulging.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Heart: The heart can be assessed while the newborn is calm or asleep to obtain an accurate heart rate and rhythm. Auscultating early avoids startling the infant, allowing for a more reliable assessment.
B. Abdomen: The abdomen should be examined while the newborn is relaxed, as palpation can disturb or wake the baby. Performing this assessment early ensures accurate findings without excessive movement or crying.
C. Lungs: The lungs can be auscultated while the newborn is sleeping to hear clear, unobstructed breath sounds. A quiet, sleeping state minimizes crying, which can interfere with accurate assessment.
D. Throat: The throat examination should be performed last because it involves handling the mouth and airway, which typically awakens or irritates the newborn. This can lead to crying and distress, making it harder to assess other systems afterward.
Correct Answer is C
Explanation
A. Check tube placement: Tube placement should be verified before administering any medication to ensure that the tube is in the stomach and not the respiratory tract. Checking placement afterward does not prevent complications from incorrect placement.
B. Retape the tube: Retaping may be necessary if the tube is loose, but it is not the priority action after giving medication. The immediate concern is maintaining tube patency and preventing clogging.
C. Flush the tube: Flushing the orogastric tube with sterile or tap water after medication administration is the priority. It ensures that the full dose of the drug enters the stomach, prevents drug interactions or residue buildup in the tubing, and maintains patency.
D. Remove the tube: The orogastric tube should not be removed unless specifically ordered or if there is a clinical reason. Removal immediately after medication administration would prevent ongoing nutritional or medication use and is not a standard practice.
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