The nurse is observing a graduate nurse's assessment of a postpartum client. For which action by the graduate nurse should the nurse intervene?

Question

1. Asking the client to void before applying clean gloves
2. Instructing visitors to leave the room prior to beginning the assessment
3. Requesting the client lie flat in bed with the head on a pillow prior to the fundal assessment
4. Discussing the effectiveness of comfort measures while performing the perineal assessment

Answer 1

2
Explanation:
1. Voiding prior to the assessment helps ensure comfort; clean gloves prevent exposure to body fluids.
2. The nurse should allow the client to choose whether visitors leave or remain in the room during the assessment.
3. The supine position prevents a falsely high assessment of fundal height.
4. The assessment provides an excellent opportunity for teaching about good healthcare practices in both the short and long term, including comfort measures.