The nurse is observing a new graduate's assessment of a postpartum patient. Which action by the student nurse should prompt a corrective intervention by the preceptor nurse?
1. Ask the patient to void, and don clean gloves.
2. Discussing the effectiveness of patient comfort measures while performing the perineal assessment.
3. Instructing the patient's visitors to leave the room prior to beginning the assessment.
4. Requesting that the patient lie flat in bed with her head on a pillow prior to the fundal assessment.
Correct Answer:
Rationale 1: Voiding prior to the assessment helps ensure comfort; clean gloves prevent exposure to body fluids.
Rationale 2: The assessment provides an excellent opportunity for teaching about good healthcare practices in both the short and long term, including comfort measures.
Rationale 3: The nurse should allow the patient to choose whether visitors leave or remain in the room during the assessment.
Rationale 4: The supine position prevents a falsely high assessment of fundal height.
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