The nurse is preparing to assess a laboring primiparous patient who has just arrived in the labor and birth unit. Which statement by the patient indicates that additional education is needed?
1. "You are going to do a vaginal exam to see how dilated my cervix is."
2. "The reason for a pelvic exam is to determine how low in the pelvis my baby is."
3. "When you check my cervix, you will find out how thinned out it is."
4. "After you assess my pelvis, you will be able to tell when I will deliver."
4
Rationale 1: Cervical dilation is one aspect of the pelvic exam assessment.
Rationale 2: Determining the station of the presenting part is one aspect of the pelvic exam assessment.
Rationale 3: Cervical effacement, or the thinning of the cervix, is one aspect of the pelvic exam assessment.
Rationale 4: An experienced labor and birth nurse can estimate the time of delivery based on the cervix, fetal position, station, and contraction pattern. However, during a pelvic exam, no information is obtained about contractions. The nurse will not have enough information following the cervical exam to estimate time of birth.
You might also like to view...
The nurse is assessing the client's cardiovascular system. The nurse is preparing to assess the client for the presence of a lift or heave. Which directions should the nurse provide for the client? Select all that apply
1. "I am going to put you into a position where your feet are actually above your head." 2. "I need you to turn to your left side." 3. "Can you please turn onto your stomach?" 4. "I need you to sit up straight." 5. "I am going to elevate your head to a 30-degree angle while you lie on your back."
On auscultation, a nurse detects a heart murmur. What should the nurse know that a heart murmur indicates?
a. Valves that do not close correctly b. Pericardium that is inflamed c. Decrease in pacemaker cells d. Loud ventricular gallop
There are many factors that influence the decision to use a specific drug regimen. Consideration of which of the following factors includes evaluating the drug's therapeutic index?
a. Safety b. Tolerability c. Efficacy d. Price e. Simplicity of use
A nurse is being sued. During this suit, the "reasonable person" standard is being addressed. This standard asks:
a. what a reasonable nurse would do in a similar situation. b. if the action taken was reasonable in the eyes of the plaintiff. c. if the institution's standards were reasonable. d. what the public considers to be a reasonable action.