The client receiving a cleansing enema complains of pain and ...

[brutforce]

The client receiving a cleansing enema complains of pain and cramping. The nurse takes which of the following corrective actions?
 
  1. Discontinue the enema.
  2. Reassure the client, and continue the flow.
  3. Raise the enema bag so that the solution can be completed quickly.
  4. Clamp the tubing for 30 seconds, and restart the flow at a slower rate.

Question 2

The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The physician has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of:
 
  1. A softening of the cervix
  2. The presence of fetal movement
  3. The presence of human chorionic gonadotropin (hCG) in the urine
  4. A soft blowing sound that corresponds to the maternal pulse while auscultating the uterus

[pallen55]

Answer to Question 1

4

Rationale: Enema fluid should be administered slowly. If the client complains of fullness or pain, stop the flow for 30 seconds and restart at a slower rate. This action decreases the likelihood of intestinal spasm and premature ejection of the solution. Therefore discontinue the enema, reassure the client, and continue the flow, and raise the enema bag so that the solution can be completed quickly are incorrect actions.

Answer to Question 2

1

Rationale: In the early weeks of pregnancy, the cervix becomes softer as a result of pelvic vaso-constriction, causing Goodell's sign. Cervical softening is noted by the examiner during pelvic examination. A soft blowing sound that corresponds to the maternal pulse may be auscultated over the uterus and is caused by blood circulation through the placenta. The presence of hCG is noted in the maternal urine in a urine pregnancy test. Goodell's sign does not indicate the pres-ence of fetal movement.