A nurse is performing an abdominal assessment as part of a client's comprehensive physical examination. Which of the following is the final step the nurse should perform?

Auscultation

Inspection

Palpation

Percussion

Answer and Explanation

The Correct Answer is C

Rationale:

A. Auscultation: This step is performed after inspection and before percussion or palpation to avoid altering bowel sounds. It allows the nurse to assess for the presence, frequency, and character of bowel sounds without stimulating them artificially.

B. Inspection: This is the first step in the abdominal assessment. It involves visually examining the abdomen for contour, symmetry, skin changes, pulsations, or visible masses without touching the patient, helping establish a baseline.

C. Palpation: Palpation is the final step in abdominal assessment to prevent interference with bowel sounds. It allows the nurse to detect tenderness, masses, or organ enlargement, but should only be done after auscultation and percussion.

D. Percussion: This is done after auscultation and provides information on underlying structures, such as gas, fluid, or masses. It helps differentiate between dullness, resonance, or tympany across abdominal quadrants.

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Correct Answer is C

Explanation

Rationale:

A. "You should avoid vaginal spermicides while breastfeeding.": Vaginal spermicides are generally considered safe during breastfeeding. They do not contain hormones and do not affect milk production, so avoidance is not typically necessary unless the client has specific contraindications.

B. "The lactation amenorrhea method is effective for your first year postpartum.": This method is only effective during the first 6 months postpartum, provided the mother is exclusively breastfeeding and menstruation has not resumed. Beyond that period, the risk of ovulation increases and it becomes unreliable.

C. "Place the transdermal birth control patch on your upper outer arm.": The patch can be applied to several sites, including the upper outer arm, abdomen, buttock, or upper torso. This is an appropriate instruction and part of standard patient teaching for transdermal contraceptive use.

D. "You can continue to use the diaphragm you used before your pregnancy.": The diaphragm often requires refitting postpartum due to changes in vaginal tone and cervix position. Using the same diaphragm without evaluation could reduce effectiveness and increase risk of unintended pregnancy.

A. "Begin each feeding using the same breast." B. "Supplement breastfeedings with water every 12 hours." C. "Offer your infant the breast when he shows signs of hunger." D. "Limit the time your infant feeds to 10 minutes on each breast

Correct Answer is C

Explanation

Rationale:

A. "Begin each feeding using the same breast.": It's recommended to alternate breasts between feedings to ensure both breasts are emptied regularly. This helps maintain milk production and prevents engorgement or blocked ducts.

B. "Supplement breastfeedings with water every 12 hours.": Newborns do not require supplemental water. Breast milk provides all the necessary hydration and nutrients for the infant’s needs, even in hot weather.

C. "Offer your infant the breast when he shows signs of hunger.": Feeding on demand based on hunger cues—such as rooting, sucking motions, or hand-to-mouth activity—supports adequate nutrition, growth, and milk supply.

D. "Limit the time your infant feeds to 10 minutes on each breast.": Feeding should not be time-restricted. Infants should be allowed to feed until they are satisfied, as some may take longer to extract enough milk, especially in the early weeks.

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A nurse is performing an abdominal assessment as part of a client's comprehensive physical examination. Which of the following is the final step the nurse should perform?

Nursing Test Bank

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