During an assessment of a female patient's internal genitalia, the nurse feels a bulge along the posterior vaginal wall. The nurse recognizes that this finding is considered:
1. a prolapsed uterus.
2. a cystocele.
3. a rectocele.
4. a blocked gland.
Correct Answer: 3
Bulging of the posterior wall suggests a rectocele. Bulging of the anterior vaginal wall and urinary incontinence would suggest a cystocele. Protrusion of the cervix or uterus into the vagina indicates uterine prolapse. The vagina does not contain glands but rather is lubricated by mucus-producing cells. Skene's and Bartholin glands are located between the labia in the vestibule.
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A nurse assesses a client with mitral valve stenosis. What clinical manifestation should alert the nurse to the possibility that the client's stenosis has progressed?
a. Oxygen saturation of 92% b. Dyspnea on exertion c. Muted systolic murmur d. Upper extremity weakness
A toddler is displaying signs and symptoms of weakness and muscle atrophy
The pediatric neurologist suspects it may be a lower motor neuron disease called spinal muscular atrophy (SMA). The patient's family asks how he got this. The nurse will respond A) "This could result from playing in soil and then ingesting bacteria that are now attacking his motor neurons." B) "No one really knows how this disease is formed. We just know that in time, he may grow out of it." C) "This is a degenerative disorder that tends to be inherited as an autosomal recessive trait." D) "This is a segmental demyelination disorder that affects all nerve roots and eventually all muscle groups as well."
The theorist who uses psychosocial developmental tasks as milestones for maturity is:
a. Piaget b. Kohler c. Maslow d. Erikson
A nurse is preparing an intravenous IV piggyback infusion. In which order will the nurse perform the steps, starting with the first one?
1. Compare the label of the medication with the medication administration record at the patient's bedside. 2. Connect the tubing of the piggyback infusion to the appropriate connector on the upper Y-port. 3. Hang the piggyback medication bag above the level of the primary fluid bag. 4. Clean the main IV line port with an antiseptic swab. 5. Connect the infusion tubing to the medication bag. 6. Regulate flow. a. 5, 2, 1, 4, 3, 6 b. 5, 2, 1, 3, 4, 6 c. 1, 5, 4, 3, 2, 6 d. 1, 5, 3, 4, 2, 6