MODULE 9

Gloving

STERILE GLOVING

 Sterile gloves help prevent the transmission of pathogens by direct and indirect contact.
 Nurses apply sterile gloves before performing sterile procedures such as inserting urinary catheters or
applying sterile dressings.
 It is important to choose not only the right size of glove but also the correct material.
 Many patients and health care workers are allergic to latex, the natural rubber used in most gloves and
other medical products.

INDIVIDUALS AT-RISK OF LATEX ALLERGY

1. Spina Bifida - a condition that affects the spine and is usually apparent at

birth.
2. Congenital or urogenital defects - birth defects and inherited conditions
that affect the urinary tract (kidneys, ureters, and bladder) or the genital tract
(reproductive organs) also called the genitourinary system.
3. History of indwelling catheters or repeated catheterization
4. History of using condom catheters
5. High latex exposure
6. History of multiple childhood surgeries
7. History of food allergies

LEVELS OF LATEX REACTIONS

1. Irritant dermatitis - A nonallergic response characterized by skin redness and itching.
2. Type IV hypersensitivity - Cell-mediated allergic reaction to chemicals used in latex processing. Reaction
including redness, itching, and hives, can be delayed up to 48 hours. Localized swelling, red and itchy or runny
eyes and nose, and coughing may develop.
3. Type I allergic reaction - A true latex allergy that can be life-threatening. Reactions vary based on type of
latex protein and degree of individual sensitivity, including local and systemic. Symptoms include hives,
generalized edema, itching, rash, wheezing, bronchospasm, difficulty breathing, laryngeal edema, diarrhea,
nausea, hypotension, tachycardia, and respiratory or cardiac arrest.

STEPS IN STERILE GLOVNG

PROCEDURE RATIONALE
1. Remove jewelry particularly rings.  Rings may tear the glove and can harbor
microorganisms.
2. Wash hands  To minimize the transfer of microorganism.
3. Remove outer paper carefully by separating and  To prevent inner glove package from accidental
peeling apart sides and lay it on clean, flat surface. opening and touching the contaminated objects.
4. Open inner wrapper and touching only the outside,  The outer portion of the inner wrapper is
secure both flaps in open position. contaminated. Inner portion of the wrapper is
sterile.
5. Identify right and left glove. Each glove has cuff  Proper identification of gloves prevents
approximately 5 cm and 2 inches wide. Glove dominant contamination by improper fit. Gloving dominant
hand. hand first promotes efficiency.
6. With thumb and first two fingers of non-dominant  The inner of the first glove is now contaminated
hand, grasp the inner fold of the cuff. Lift the glove, because it has been in contact with nurse’s hand.
holding away from the body. Slip dominant hand The outer surface of the glove remains sterile.
touching only the inner surface of the glove.
7. With gloved dominant hand, slip four fingers  Contact of gloved hand with exposed hand results
underneath second glove cuff. Lift the glove away from in contamination.
the body. Slide the second hand into the second glove,
touching only the inner part of the glove.
8. Carefully pull second glove over non-dominant hand  If a sterile object (first gloved hand) touches a
and adjust fingers of both gloves using gloved hand. second sterile object (second gloved hand) both
remains sterile.
9. After second glove is on, interlock hands together  Below waist level is considered contaminated.
above waist level. The cuffs usually fall down after
application. Be sure to touch only sterile sides.

GLOVE DISPOSAL

10. Grasp outside of one cuff with other gloved hand,  Minimizes contamination of underlying skin
avoid touching the wrists.
11. Pull glove off, turning it inside out.  Outside of glove should not touch the skin.
12. Take fingers of bare hand and tuck inside remaining  This method neatly encloses the used object in the
glove cuff. Peel glove off inside out and over previously glove, making disposal more sanitary.
removed glove. Discard both gloves in receptacle.

Check for Understanding:

1. A nurse with a latex allergy needs to perform a sterile procedure and finds that the only sterile gloves available
are latex. Which action by the nurse would be most effective in solving the problem?
A. Rubbing petroleum jelly on the hands to provide a barrier between the hands and the gloves
B. Putting a pair of synthetic gloves on before donning the latex sterile gloves
C. Using a larger pair of sterile gloves so they’re not as tight
D. Rinsing the hands with cold water before putting on the sterile gloves

2. When opening a sterile pack, which action compromises the sterility of the contents?
A. Keeping the contents of the pack away from the table edge
B. Holding or moving the object below the waist
C. Opening the pack just before the procedure
D. Allowing movement around the sterile field that does not touch near the sterile field

3. A nurse is preparing to change a dressing using sterile gloves. It is most important to remember which concept
when putting them on?
A. Grab only the inside of the glove with the ungloved hand.
B. Grab only the cuffs of the gloves with the bare hand.
C. Wear a glove that is as tight as possible.
D. Keep the glove fingertips parallel to the body.
4. A teenager with spina bifida is to have a urinary catheter inserted. Which action is most important before
performing this procedure?
A. Washing the insertion area with soap and water before insertion of the catheter
B. Positioning the patient as comfortably as possible
C. Asking the patient if he or she is allergic to eggs
D. Obtaining a nonlatex catheter for the procedure

5. A nurse is supervising a nursing student setting up for a sterile dressing change. Which action by the nursing
student would require intervention from the nurse?
A. The first flap of the sterile package is opened away from the student’s body.
B. The glove for the dominant hand is pulled on first.
C. When pouring a solution on to the sterile field, the label of the solution bottle is facing the floor.
D. The bottle of solution is kept above the student’s waist.

6. Sterilization of surgical instruments and surgical dressings is accomplished by using:

A. An autoclave.
B. Soap and water.
C. Ethylene oxide gas.
D. Chemicals such as alcohol.

7. A nurse has a cold and needs to change a dressing on a patient who is immunocompromised. Which action by the
nurse would be most appropriate?
A. Asking another nurse to change the dressing
B. Wearing a gown and mask when changing the dressing
C. Performing hand hygiene for a longer time before putting on sterile gloves
D. Asking the patient if it’s all right with him if he changes the dressing

8. In setting up a sterile field, which of the listed actions would require intervention?
A. The bottle of solution is poured with the label facing up.
B. The sterile drape is allowed to unfold above the waist.
C. The first flap of the sterile package is opened toward the nurse.
D. The glove for the dominant hand is pulled on first.

9. When performing a sterile procedure at the bedside, the Nursing Assistant can help by assisting the nurse to
______________ the patient.
A. Mechanics
B. Position
C. Application
D. Intervention

10. Place an S next to the procedures requiring sterile (aseptic) technique. (Select all that apply.)
A. Urinary catheterization
B. Insertion of a feeding tube
C. Tracheal suctioning
D. Lumbar puncture
E. Insertion of a rectal suppository
F. Sitz bath
 MODULE 10
Catheterization

Catheterization
 Urinary catheterization is the placement of a tube through the urethra into the bladder to drain urine.
 This is an invasive procedure that requires a medical order and aseptic technique in institutional settings.
 May be short term (2 weeks or less) or long term (more than 1 month).

SAFETY GUIDELINES
 Follow principles of surgical and medical asepsis as indicated when performing catheteruzations,
handling urine specimens, or helping with their toilet needs.
 Identify patients at risk for latex allergies.
 Identify patients with allergies to povidone-iodine (Betadine). Provide alternatives such as chlorhexidine.

PURPOSE
1. Facilitates evacuation of urine.
2. Obtains a sterile specimen as needed.
3. Monitors the urine output.
4. Determines amount of residual urine.
5. Prevents strain on pelvic or abdominal wound from distended bladder.
6. Empties the bladder before and during surgery and before certain diagnostic procedure.

EQUIPMENT
1. Catheter of correct size and type for procedure or patient condition.
A. Indwelling - double lumen 14 or 16 Fr
B. Intermittent - usually 12 to 14 Fr
Note: Some kits contain a catheter with attached drainage bag; others contain only a catheter; others have no
catheter.
2. Drapes - (one fenestrated --- has an opening in the center)
3. Sterile glove
4. Lubricant
5. Antiseptic cleaning solution such as chlorhexidine or povidone-iodine incorporated in an applicator or
to be added on cotton balls.
6. Specimen container
7. Prefilled syringe with sterile water for balloon inflation of an indwelling catheter.

STEPS IN CATHETERIZATION
PROCEDURE RATIONALIZATION
1. Gather equipment needed.  To promote efficiency in the procedure.
2. Check for the doctor’s order, the consent and identify  To allay fear and anxiety of the patient regarding
the client and explain the procedure. his condition and the procedure.
3. Wash hands.  For infection control.
4. Assist the client to an appropriate position and drape  To relax muscles and allow visualization of the
all areas except the perineum. area to facilitate the insertion of the catheter.
A. Female - dorsal recumbent

B. Male - supine with legs slightly abducted.

5. Establish adequate lighting.  Good lighting is necessary to see the perineum
clearly.
6. Open the catheterization set and arrange the sterile  Placement of equipment in order of use increases
field. the speed of performance and decrease the risk of
contamination.
7. Set-up receptacle for soiled cleaning swabs.  To facilitate systematic action.
8. If drainage bag is in separate bag, open and attach it  To reduce the risk of infection by keeping the bag
to the bed. off the flow is grossly contaminated.
9. Put on sterile gloves.  To prevent contamination.
10. For an indwelling catheter, attach syringe and test  To check for the balloon patency and for a defect
balloon by instilling sterile water and deflating balloon by in the catheter.
withdrawing the water.
11. If drainage bag is in set, connect distal end of  To prevent urine spilling from a collecting
catheter to drainage tubing. container while performing the procedure.
12. Clean urinary meatus with antiseptic solution using a  To remove dirt and minimize the risk of urinary
downward stroke. tract infection by removing surface pathogens.
13. Lubricate the distal portion of the catheter and place  To reduce friction and possible irritation as
it on a nearby sterile field. catheter is inserted.
14. Insert the catheter gently, in rotating motion.  For female - To relax the sphincter, in order to
Instruct the client to take a slow deep breath upon facilitate the insertion of catheter.
insertion.
A. For male patient (6 to 9 inches), hold the penis  For male - To straighten the urethra and facilitate
at 45-degree angle until urine flows. the insertion.

B. For female patient, (2 to 3 inches), gently

spread the labia minora with your finger and
visualize the urinary meatus and steadily insert the
catheter.
15. Inflate the retention ballon with sterile water.  To prevent the catheter from slipping out of
position.
16. Tape the catheter;  To prevent pull on the neck of the bladder as the
A. To the thigh of female patient and patient moves.

B. To the lower abdomen for a male patient.

17. Secure the drainage tubing and place drainage bag  To allow bladder to drain freely by gravity.
below the level of the bladder.
18. Assist the client to a comfortable position.  To provide comfort and safety.
19. Gather and discard disposable equipment.  To prevent contamination.
20. Remove gloves and do handwashing.  To prevent the transmission of microorganisms
21. Document the procedure.  Provides accurate data in the care of the cleint.

REMOVAL OF INDWELLING CATHETER

PROCEDURE RATIONALE
1. Check the physician’s order.  A written order from the physician is needed for
the removal of the catheter.
2. Wash hands.  To prevent the transmission of microorganisms.
3. Assemble the equipment.  To promote efficiency.
4. Identify the client and explain the procedure.  To allay fear and facilitate cooperation.
5. Remove covers and drape to expose the catheter  To protect client privacy aqnd reduce
but do not overly expose the perineal area. embarassment.
6. Wear clean gloves.  To avoid contact with secretions.
7. Place protective pad under the patient’s thigh.  To prevent the bed from becoming soiled.
8. Empty urine tubing into catheter bag.  To prevent leakage from the catheter.
9. Remove any tape that may be holding the catheter  To allow easy removal of catheter.
to the leg.
10. Insert syringe into the balloon port and pull the  To ensure the ability to drain the contents of the
plunger to remove all the air or fluid from the balloon.
balloon.
11. Ask the client to take a deep breath if able and  Damage to the urethra may occur if the balloon is
gently pull out the catheter. Stop if resistance is not fully deflated.
felt, and recheck the balloon port.
12. Clean the client’s perineal area.  To provide comfort.
13. Dispose material used and remove gloves.  To prevent contamination of the environment.
14. Wash hands.  For infection control.
15. Document pertinent data.  To provide accurate data in care of the patient.

Check for Understanding:

1. When preparing to discharge a patient who had an indwelling urinary catheter removed 24 hours ago, the nurse
would offer patient education regarding which common complication?
A. Urinary incontinence
B. Urinary tract infection
C. Adequate oral hydration
D. Kidney stones

2. Which action would best minimize a patient's risk for infection during removal of an indwelling urinary catheter?
A. The nurse or nursing assistive personnel (NAP) removing the catheter must employ clean technique.
B. A registered nurse, not NAP, must remove the catheter.
C. Catheter removal must be executed within 10 minutes of beginning the procedure.
D. Catheter removal must take place within 5 days of catheter insertion.

3. Which statement might the nurse make to nursing assistive personnel (NAP) caring for a patient who has just had
an indwelling urinary catheter removed?
A."Teach the patient the signs of a urinary tract infection."
B. "Tell me when and how much the patient first voids."
C."Explain that voiding might be uncomfortable for 4 to 5 days."
D."Assess the patient for a distended bladder before the end of the shift."

4. Which nursing action minimizes a patient's risk for injury during removal of an indwelling urinary catheter?
A. Using a 5-mL syringe to deflate the balloon.
B. Using sterile scissors to cut the valve to deflate the balloon.
C. Tugging gently on the catheter to pull the balloon through the urethra.
D. Checking the documentation for the volume of fluid used to inflate the balloon.

5. Which is not an expected outcome on a first voiding after catheter removal?

A. Mild burning
B. Fever and back pain
C. Producing only a small amount of urine
D. Discomfort

6. Which action would the nurse take to reduce the risk for a catheter-associated urinary tract infection (CAUTI) in a
patient with an indwelling urinary catheter?
A. Wear clean gloves when inserting the catheter.
B. Inflate the balloon on the catheter before using it.
C. Use the smallest-size catheter possible.
D. Empty the urine by disconnecting the catheter from the collection bag.

7. Which action(s) would minimize the patient’s risk for injury during insertion of an indwelling urinary catheter?
A. Assessing the patient for allergies related to latex, antiseptic, tape, and/or iodine-based substances.
B. Thoroughly cleansing the patient’s perineal area with povidone-iodine solution before inserting the catheter.
C. Performing proper hand hygiene and applying gloves before inserting the catheter.
D. Terminating the insertion if the patient reports pain at any time during the procedure.

8. Which statement best illustrates the nurse’s understanding of the role of nursing assistive personnel (NAP) when
inserting an indwelling urinary catheter in a female patient?
A. “Please direct the light to better illuminate the patient’s perineal area.”
B. “You need to be comfortable inserting a catheter in a patient of her size.”
C. “See if a size 14-French catheter is big enough.”
D. “Find out if the patient has any allergies to latex or iodine.”

9. The nurse has completed the initial inspection of the patient’s perineum and is preparing to insert an indwelling
urinary catheter. Which action would the nurse complete next?
A. Begin to establish a sterile field.
B. Open and assemble the urine drainage bag.
C. Remove soiled gloves, and perform hand hygiene.
D. Center the drape over the patient’s labia.

10. A female patient placed in the dorsal recumbent position for the insertion of an indwelling urinary catheter tells
the nurse that she “doesn’t feel comfortable in this position” and that her “back really hurts.” What is the nurse’s
best response?
A. Reassure the patient that the procedure will take only a few minutes.
B. Promise to reposition the patient as soon as the catheter has been inserted.
C. Reposition the patient in a side-lying position, with her upper leg flexed at the knee and hip.
D. Explain to the patient that the position will allow the catheter insertion to be more efficient.
 MODULE 11
Pelvic Examination

Pelvic Examination
 Is examination typically performed with a patient supine, legs in dorsal lithotomy position, and feet
resting in stirrups.
 The head of the bed is elevated 30 degrees to relax abdominal wall muscles or bimanual examination.
 A woman is assured that she may stop or pause the examination at any time.
 A pelvic examination is usually scheduled at the time the girl becomes sexually active, at 21 years of age,
or at the first sign of a gynecologic order.
 Pelvic exam is an important part of the exam for female patients and important towards making various
diagnoses such as yeast vulvovagintis, bacterial vaginosis, lichen sclerosis, cancers such as cervical
cancer, anal/rectal cancer, fibroids, STIs (gonorrhea, chlamydia, trichomonas, syphilis, herpes and
human papillomavirus/genital warts) and many other diagnoses.
 A pelvic examination reveals information on the health of both a woman’s internal and external reproductive
organs.

Pelvic examination includes;

1. Inspection of the external genitalia
2. Vaginal examination
A. Inspection of the cervix and vaginal walls.
B. Palpation of the vagina and vaginal cervix by digital examination.
C. Bimanual examination of the pelvic organs.
D. Rectal examination
E. Rectovaginal examination

EQUIPMENTS
1. A speculum - the main equipment you will use is the speculum so it’s important for you to understand the
most commonly used types.
Note: These are cold! Important to keep in warmer temperatures or run under warm water prior to use.

 VAGINAL SPECULA
1. Pediatric Pederson  This may be selected for child,
speculum adolescents, or virginal adult
examination.
2. Graves speculum or  This may be selected for
Duckbill speculum examination of parous women
with relaxed and collapsing
vaginal walls.

 A liitle wider and often used

for the procedure.

3. Pederson speculum  This may be selected for

sexually active women with
adequate vaginal wall tone.

 Speculums comes in various sizes:

2. A spatula and/or broom for cervical sampling.

3. Clean examining gloves
4. Lubricant
5. A glass slide or liquid collection device for a Pap smear.
6. A culture tube
7. Two or three sterile cotton-tipped applicators or cytobrushes for obtaining cervical cultures.
8. A good examining light
9. A movable stool at correct sitting height
- A lithotomy position used for pelvic examination.
 STEPS IN PELVIC EXAMINATION
PROCEDURE RATIONALE
1. Secure patient’s consent and explain the procedure  The test may be adequately explained and
to the patient. understood by the patient before a written, and
informed consent is obtained.
2. Advise the patient to urinate before positioning the  To lessen the anxiety of the patient and allow the
client to a lithotomy position. woman the opportunity to talk with the person
performing the examination while sittong up,
before being placed in a lithotomy position,
because this can enhance her sense of self-esteem
and control.
3. Help position a woman with her buttocks just over  Draping the patient with a draw sheet over her
the edge of the table and drape appropriately. abdomen that extends over her legs for modesty.
4. Examine the vulvar region for erythema and other  A pelvic examination begins with inspection of
rashes. the external genitalia. Any signs of inflammation,
infection, ulcerations, lesions, vagional discharge,
or circumcision are noted.
5. Insert a warm-lubricated vaginal speculum and  Cold and unlubricated speculum when inserted
instruct the woman to take a deep breath while can be a bit uncomfortable with patients.
inserting the speculum.
 Instructing the patient to take a deep breath will
1. Blades held obliquely on entering the vagina. help relax the perineal muscles.

2. Blades rotated to horizontal position as they

pass the introitus.

3. Blades separated by depressing thumbpiece

and elevating handle. The position of the blades is
maintained by adjusting a thumbscrew.
6. Open the speculum and adjust until the cervix is in  The uterine cervix is centered in the vagina;
sight and lock open. A. The cervix of a retroverted uterus will be
positioned anteriorly.
If planned, conduct pap smear and STD testing,
cytobrush is inserted. B. The cervix of an anteverted uterus is
positioned posteriorly.

 The cervix color

A. A nonpregnant cervix is light pink

B. In pregnancy, it changes to almost purple.

C. Any lesions, ulcerations, discharge, or otherwise

abnormal apperance are documented.

 In a nulligravida, the cervical os appears round

and small.
  In a woman who has had a previous vaginal
birth, the cervical os has much more of a slitlike
appearance.

 If a woman had a cervical tear during a

previous birth, the cervical os may appear as a
transverse crease the width of the cervix or a
typical star-like (stellate) formation.
7. Insert index finger and possibly additional finger  When performing bimanual exam look for the
(with lubricant) in vaginal canal with non-dominant following:
hand to palpate the abdomen.
1. Cervical motion tenderness - could suggest
cervicitis or pelvic inflammatory disease.

2. Position of uterus (image in folder) - helpful

to know if you may not be able to palpate uterus if
axial or retroflexed.

3. Adnexal size and tenderness - looking for

any adnexal masses.
A. Obesity may create a challenge to
appreciating the adnexa.

B. The post-menopause ovary can often be

too small to palpate.
8. Place lubricant on index and middle finger of  The purpose of the exam is to:
dominant hand then insert index finger into Appreciate a retroflexed uterus and adnexal
vaginal canal. masses. Look for presence of hemorrhoids,
polyps/growths and assess the tone of the rectal
sphincter.
9. Insert middle finger into rectum, asking patient to  Appreciate
bare down and insert fingers as far possible. A. Retroflexed uterus

B. Nodularity along uteral sacral ligament and cul-

de-sac behind uterus - suggesting endometriosis.

 To find ureteral sacral ligament, pull the cervix

anterior with index finger to stretch and palpate
for the ligament with finger inserted into rectum.

C. Adnexa - looking for masses and tenderness

D. Rectal or anal masses/polyps

Check for Understanding:

1. What is included in the preparation for an assessment of the female genitalia?
A. Having the patient empty the bladder
B. Explaining the exam thoroughly if it is the patient’s first exam
C. Laying the head of the table flat
D. Both A and B

2. When should gloves be changed or discarded?

A. After touching the genital skin
B. After completing the internal vaginal exam
C. After completing the rectal exam
D. All of the above

3. Which description is consistent with normal vaginal secretions?

A. Clear, thick, and with a fishy odor
B. Clear or cloudy, and odorless or with a slight odor
C. Yellow, thin, and with a strong odor
D. Green, thick, and with a foul odor

4. The following are true regarding Vaginal examination, EXCEPT:

A. Inspection of the cervix and vaginal walls
B. Palpation of the vagina and vaginal cervix by digital examination
C. Bimanual examination of the pelvic organs
D. Rectal examination

5. Screening for endometrial cancer consists of reinforcing the need to report:

A. Bloody stools
B. Painful bowel movements
C. Unexpected vaginal bleeding or spotting
D. Green or yellow vaginal discharge

6. The nurse is delegating to nursing assistive personnel (NAP) the perineal care of a female patient who is totally
dependent and confined to bed. Which statement by the NAP requires the nurse's follow-up?
a. "I'll ask for assistance if I need help positioning her."
b. "I'll see if she's up to the care right now."
c. "I'll let you know if I notice any signs of redness or discharge."
d. "I'll be sure to use hot, soapy water, since she has been incontinent."

7. The nurse is preparing to provide perineal care for a female patient who is on bed rest. Which patient position
should the nurse use for this care?
a. Supine
b. Prone
c. Side-lying
d. Dorsal recumbent

8. As the nurse is preparing to provide perineal care to a female patient with limited mobility, the patient says, "I can
do that myself." Which action would be the priority?
a. Provide all the necessary supplies and linen for this task.
b. Assess the patient's ability to perform proper perineal care.
c. Ensure that the patient has privacy while performing perineal care.
d. Document any complaints of irritation or pain in the perineal area.
9. How can the nurse promote infection control while providing perineal care for a female patient who has a catheter?
a. By avoiding the application of tension on the catheter
b. By patting, not rubbing, the skin dry after thoroughly rinsing it
c. By cleansing the patient's labia from the pubic area toward the rectum
d. By using warm water to cleanse the patient's entire perineal area

10. The nurse is delegating a female patient's perineal care to nursing assistive personnel (NAP). Which instruction
would the nurse give to ensure the NAP's safety while performing this care?
a. Wear sterile gloves.
b. Wear clean gloves.
c. Wear an isolation gown.
d. Use hot water.
 MODULE 12
Papanicolau Smear

Papanicolau Smear
 Is taken from the endocervix at a first prenatal visit to be certain a precancerous or cancerous
condition of the uterine cervix, vulva, or vagina is not present.
 A photograph of the cervix may be taken to document the appearance of a suspicious lesion on the cervix
or confirm that a previous lesion from an infection has healed.
 Also called “Pap test” and “Papanicolau test”.
 The Pap smear is usually done in conjunction with a pelvic exam. In women older than age 30, the Pap
test may be combined with a test for HPV - a common STI that can cause cervical cancer.
 Women aged 21-29 years
 should have a Pap test every 3 years.
 Women aged 30-65 years
 should have a Pap test every 3 years.
 an HPV test every 5 years.
 or a Pap and HPV co-test every 5 years.

For woman who have risk factors, doctors will request more frequent Pap smear with women who have;
1. A diagnosis of cervical cancer or a Pap smear that showed precancerous cells.
2. Exposure to diethylstilbestrol before birth.
3. HIV Infection
4. Weakened immune system due to organ transplant, chemotherapy or chronic corticosteroid use.
5. A history of smoking.

These tests can detect;

A. Precancerous cell changes
B. The presence of HPV
C. The presence of cancer

CONSIDERATION
1. After a total hysterectomy
 Noncancerous condition, such as uterine fibroids, may be able to discontinue routine Pap smears.
 Hysterectomy was for a precancerous or cancerous condition of the cervix, the doctor may recommend
continuing routine Pap testing.

2. Older age
 Stopping routine Pap testing at age 65 if their previous tests for cervical cancer have been negative.
 Sexually active with multiple partners, may recommend continuing Pap testing.

3. Women who engage in anal intercourse may have an anal swab taken as well as vaginal swabs to detect
anal squamous neoplasms.
4. The technique for obtaining an anal Pap smear is the same as that for vaginal specimens (a
cytobrush is used).
5. Caution the patient that she may have slight rectal bleeding following this procedure so she isn’t
unnecessarily concerned.
 INTERPRETATION OF PAP SMEAR BY THE BETHESDA SYSTEM
FINDINGS INTERPRETATIONS
1. Negative  No precancerous or cancerous cells are found

SQUAMOUS CELLS
1. Atypical squamous cells (ASC)  Some cells appear different than normal but
cannot be classified as precancerous.
2. Low-grade squamous intraepithelial lesion  Mild precancerous changes may have been
(LSIL) found in some cells.
3. High-grade squamous intraepithelial lesion  Moderate to severe precancerous changes
(HSIL) may have been found in some cells.
4. Squamous cell carcinoma  Cancerous cells are present.

GLANDULAR CELLS
1. Atypical glandular cells  There is an increase risk of precancer or
cancerous cells.
2. Adenocarcinoma  Cancerous cells are present.

VAGINAL INSPECTION EXAMINATION OF THE PELVIC ORGANS

 Before the vaginal speculum is removed, a  Bimanual (two-handed) examination is
culture for trichomoniasis (microscope slide wet performed to assess the position, contour,
mount sample) or group B Streptococcus (done at consistency, and tenderness of pelvic organs
35 to 37 weeks gestation) may be taken. following the speculum examination.

 Some Pap test can be analyzed for gonorrhea,  Abnormalities that can be noted by bimanual
chlamydia, and HPV, so a separate swab for these examination includes;
infections is not required. 1. Ovarian cysts

 Treatment to eliminate all of these infections 2. Enlarged fallopian tubes (perhaps from
during early pregnancy helps guard maternal, pelvic inflammatory disease)
fetal, and newborn health.
3. Enlarged uterus
 In a nonpregnant woman, vaginal walls are
light pink; pregnancy may turn them dark blue to 4. An early sign of pregnacy (Hegar’s Sign)
purple.

 Any areas of inflammation, ulceration, lesions, or

discharge should be noted.
 RECTOVAGINAL EXAMINATION
 The (1) index finger is reinserted into the vagina The purpose of the exam is to:
and (2)the middle finger into the rectum after a
bimanual pelvic examination,(3) the hand is  Appreciate a retroflexed uterus and adnexal
withdrawn from the vagina. masses.

 By palpating the tissue between the  Look for presence of hemorrhoids,

examining finger in this way, it is possible to polyps/growths and assess the tone of the rectal
assess the strength and irregularity of the sphincter.
posterior vagina wall.
1. Place lubricant on index and middle finger of
 This maneuver may be slightly dominant hand then insert index finger into vaginal
uncomfortable for a woman because of rectal canal.
pressure.
2. Insert middle finger into rectum, asking patient to
 After completing the examination, any excess bare down and insert fingers as far possible.
lubricant is wiped away from the vaginal and rectal
openings. 3. Appreciate
A. Retroflexed uterus
 Be certain to wipe front to back to prevent
bringing rectal contamination forward from the B. Nodularity along ureteral sacral ligament
rectum to vagina. and cul-de-sac behind uterus - suggesting
endometriosis.

To find uretral sacral ligament, pull the cervix

anterior with index finger to stretch and palpate for the
ligament with finger inserted into rectum.
C. Adnexa - looking for masses and tenderness

D. Rectal or anal polyps/masses

SPECIAL CONSIDERATIONS
1. Hospitalized patients - given a proper exam table
with leg rests is often not available, if possible delay this
exam until patient can be seen in clinic.
 However if speculum exam is needed
immediately, one method is to place an
inverted bedpan under the patient’s buttocks to
raise pelvis.

 If yeast vulvovaginitis is suspected, you or a

patient can obtain a swab and look under
microscope or send to lab.

2. Patient’s first exam or elderly patients - may

require more discussion and education prior to the
exam.
 3. Patients with history of trauma - ensure patient
knows they have control and can stop the exam at any
time.

Check for Understanding:

1. Which of the following interventions of the nurse is considered priority in dealing with sexuality problems and
issues of the clients?
A. Identifying the personal life experiences and feelings towards the client.
B. Becoming sensitive to the client’s feelings
C. Focusing on the client’s emotional contents.
D. Portraying concern and sympathy with the client.

2. The Papanicolaou Test can detect the following, EXCEPT:

A. Pre-cancerous cell changes
B. The presence of HPV
C. The presence of genital warts
D. The presence of cancer

3. Sonia has an abnormal result on a Papanicolou test. After admitting that she read her chart while the nurse was
out of the room, Katrina asks what dysplasia means. Which definition should the nurse provide?
A. Presence of completely undifferentiated tumor cells that don’t resemble cells of the tissues of their origin.
B. Increase in the number of normal cells in a normal arrangement in a tissue or an organ.
C. Replacement of one type of fully differentiated cell by another in tissues where the second type normally isn’t
found.
D. Alteration in the size, shape, and organization of differentiated cells.

4. A 25-year-old patient is inquiring about the methods or ways to detect cancer earlier. The nurse least likely
identify this method by stating:
A. Annual chest x-ray
B. Annual Pap smear for sexually active women only.
C. Annual digital rectal examination for persons over age 40.
D. Yearly physical and blood examination

5. The nurse is counseling a mother who wants her teenage daughter to have a Pap smear and pelvic examination.
Which statement by the nurse is most accurate?
A. “If your daughter is over 18, she needs a pelvic examination and Pap smear.”
B. “A teenager does not need this examination unless she is sexually active.”
C. “Teach her to have her first examination by the age of 21 at the latest.”
D. “It is not needed unless you are worried about sexually transmitted diseases.”

6. When the results of a Pap smear are reported as class 5, the nurse recognizes that the common interpretation is:
A. Malignant
B. Normal
C. Probably normal
D. Suspicious

7. When scheduling an annual pelvic examination and Pap test, the client asks if she should abstain from intercourse
before the test. Which is the nurse’s best response?
A. “Yes Avoid having intercourse for 24 hours before the test”.
B. “Yes. Avoid having intercourse for 2 hours before the test.”
C. “No. Intercourse does not interfere with this test.”
D. “No Intercourse can actually enhance the test results”

8. The nurse is teaching high school girls about the female reproductive tract. Which statements by the nurse are
accurate, EXCEPT:
A. The vagina has an acidic environment.
B. The cervix is where the Pap smear is taken.
C. The ovum is fertilized in the uterus.
D. Ovaries produce sex steroid hormones.
E. The breasts contain fat tissue.

9. A client is in the clinic for an annual examination and questions the need for a pelvic examination and Pap smear
because she had a hysterectomy many years ago. Which response by the nurse is most appropriate?
A. Do you still have your cervix?
B. Are you sexually active?
C. We can skip it if you like.
D. Lets see what the doctor says.

10. A female client has just been diagnosed with condylomata acuminata (genital warts). What information is
appropriate to tell this client?
A. This condition puts her at a higher risk for cervical cancer; therefore, she should have a
Papanicolaou (Pap) smear annually.
B. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.
C. The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have
sexual intercourse.
D. The human papillomavirus (HPV), which causes condylomata acuminata, can’t be transmitted during oral sex.
 MODULE 13
Family Planning - Part 1

Family Planning
 Family planning is far more than simply birth control, and aims at improving the quality of life for
everybody. Family planning is an important part of primary healthcare and includes:

1. Promoting a caring and responsible attitude to sexual behavior.

2. Ensuring that every child is wanted.
3. Encouraging the planning and spacing of the number of children according to a family’s home conditions
and financial income.
4. Providing the highest quality of maternal and child care.
5. Educating the community with regard to the disastrous effects of unchecked population growth on the
environment.
6. It is essential to obtain prior community acceptance of, and promote community participation in, any family
planning program if the program is to succeed in that community.
7. Because family planning aims at improving the quality of life for everybody, every person, female or
male, requires family planning education. Such education should ideally start during childhood and be given in home
by the parents. It is then continued at school and throughout the rest of the individual’s life.
8. Every person who is sexually active, or who probably will soon become sexually active, needs
contraceptive counselling. While the best time to advise a woman on contraception is before the first
coitus, the antenatal and post-delivery periods are an excellent opportunity to provide contraceptive counselling.
Some patients will ask you for contraceptive advice. However, you will often have to first motivate a patient to
accept contraception before you can advise her about an appropriate method of contraception.
9. A good way to motivate a patient to accept contraception is to discuss with her, or preferably with
both her and her partner, the health and socioeconomic effects further children could have on her and the rest of
the family. Explain the immediate benefits of a smaller, well-spaced family.
10. It is generally hopeless to try and promote contraception by itself. To gain individual and community
support, family planning must be seen as part of total primary healthcare. A high perinatal or infant mortality rate in
a community is likely to result in a rejection of contraception.

STEPS IN FAMILY PLANNING

STEP 1: Discussion of the patient’s future Ideally a woman should consider and plan her
reproductive career family before her first pregnancy, just as she would
have considered her professional career.

Unfortunately in practice this hardly ever happens and

many women only discuss their reproductive careers for
the first time when they are already pregnant or after
the birth of the infant.

When planning her family the woman (or preferably the

couple) should decide on:

1. The number of children wanted.

 2. The time intervals between pregnancies as
this will influence the method of contraception used.

3. The contraceptive method of choice when the

family is complete.

Very often the patient will be unable or unwilling to

make these decisions immediately after delivery.

However, it is essential to discuss contraception with the

patient so that she can plan her family.

This should be done together with her partner and,

where appropriate, other members of her family or
friends.

STEP 2: The patient’s choice of contraceptive  The patient should always be asked which
method contraceptive method she would prefer as
this will obviously be the method with which she is
most likely to continue.
STEP 3: Consideration of contraindications to the You must decide whether the patient’s choice of a
patient’s preferred method contraceptive method is suitable, taking into
consideration:

1. The effectiveness of each contraceptive method.

2. The contraindications to each contraceptive

method.

3. The side effects of each contraceptive method.

4. The general health benefits of each contraceptive

method.

If the contraceptive efficiency of the preferred method is

appropriate, if there are no contraindications to it, and if
the patient is prepared to accept the possible side
effects, then the method chosen by the patient should
be used.
STEP 4: Selection of the most appropriate  The selection of the most suitable alternative
alternative method of contraception method of contraception after delivery will
depend on a number of factors including the
patient’s wishes, her age, the risk of side effects
and whether or not a very effective method of
contraception is required.
STEP 5: Counselling the patient once the  Virtually, every contraceptive method has its
contraceptive method has been chosen own side effects. It is a most important part of
contraceptive counselling to explain the possible
side effects to the patient. Expert family planning
advice must be sought if the local clinic is unable
to deal satisfactorily with the patient’s problem. If
family planning problems are not satisfactorily
solved, the patient will probably stop using any
form of contraception.

 After delivery, the reproductive career of

each patient must be discussed with her in
order to decide on the most appropriate method of
family planning to be used.

AFTER COUNSELLING
1. Once the client has undergone one-on-one counseling and has accepted a method, the provider will
generate critical information and fill out FP Form 1.

This is a two-page form with the front page divided int five sections, namely;
 Medical history

 Obstetrical history

 Assessment of risk for STI

 Assessment of risk for violence against women (VAW)

 And physical examination.

 Sociodemographic information (client’s personal data, type of acceptor and FP method used)

 Acknowledgement section with the client’s signature signifying that the client has been counseled.

The updated FP Form 1 likewise includes a section on parental/guardian consent. This is a pre-requisite for
clients below 18 years old.

The back portion is divided into columns and generates the following information:
 Date of visit

 Medical findings (medical observations, complaints, complications, services rendered/procedures, lab exams,
treatment and referrals)

 FP method/supplies given (method/brand and number of units); name of provider and signatre and date
follow-up visit.

2. CONSENT FORMS
A. PARENTAL CONSENT - to ensure compliance with Section 4.06 and 4.07 of the Implementing
Rules and Regulations of the Responsible Parenthood/Reproductive Health (RP/RH) Law, clients
below 18 years old must secure a written consent from their parents/guardian prior to availing of any FP method
from the hospital.

B. INFORMED CONSENT FORM for Methods Requiring Procedures - in the case of FP clients requiring
procedures, the following DOH FP Clinical Guideline requirements will apply with respect to documenting client
consent;

1. The FP counsellor will ensure informed consent by:

 Reinforcing counselling to avoid regret and emphasizing that BTL and NSV are permanent methods.

 Explaining to the client the six elements of informed consent written on the Informed Consent Form.

 Checking that the Informed Consent Form is signed correctly by the client.

2. Counselling must include the six elements of informed consent. When the client desires to undergo
BTL/vasectomy, she/he signs an informed consent form to prove that the following six elements have been
discussed.
1. Temporary contraceptives are available to the client.

2. Voluntary sterilization is a surgical procedure.

3. The surgical procedure involves risk, in addition to benefits. Among the risks is the possibility that the
procedure may fail.

4. The effect of the procedure should be considered permanent.

5. The procedure does not protect against STI, including HIV/AIDS.

6. The client can decide against the procedure at any time before the operation is performed without losing
the right to medical health or other services or benefits.
3. HOME-BASED FP CLIENT CARD
After filling out the FP Form 1, the client will be issued an FP Client Card.

This card serves as the FP service card of the client, which s/he will need to bring every time s/he seeks any FP
service from any facility.

It contains the following information:

 Client’s name
 Client’s number
 Age
 Client contact number
 Date of client visit
 FP service provided
 Date of expected follow-up or next service date
 Name of the facility which rendered the service and
 Name/signature of the service provider.
Check for Understanding:
A 15-year-old primigravida had a normal delivery in a district hospital. She has never used contraception. Her mother
asks you for contraceptive advice for her daughter after delivery. The patient's boyfriend has deserted her.
1. Does this young teenager require contraceptive advice after delivery?
- Yes, she will need contraceptive counselling and should start on a contraceptive method before discharge from
hospital. She needs to learn sexual responsibility and must be told where the nearest family planning clinic to her
home is for follow-up. She also needs to know about postcoital contraception.

2. Why would she need a long-term contraceptive?

- Because she should only have her next child when she has completed school, is in a stable relationship and able to
take care of her children by herself.
 MODULE 14
Family Planning - Part 2

Family Planning
Natural Family Barrier Methods Hormonal Methods Surgical Methods
Planning (Fertility (Sterilization)
Awareness-Based
Method)
1. Abstinence 1. Chemical Barriers 1. Oral route Vasectomy Tubal
 Spermicide  Combination Oral Ligation
2. Calendar Method Contraceptives
2. Mechanical Barriers
3. Basal Body  Diaphragm  Progestin-only
Temperature Oral
 Cervical Caps Contraceptives
4. Cervical Mucus
Method  Male Condom 2. Transdermal route

5. Symptothermal  Female Condoms 3. Vaginal insertion

Method
4. Implant
6. Lactation
Amenorrhea Method 5. Injection

7. Coitus Interruptus 6. Intrauterine Devices

Natural Family Planning (Fertility Awareness-Based Method)

Natural Family Planning (Fertility Awareness- Abstinence
Based Method)  Refraining from sexual intercourse.
 “periodic abstinence method”
 The single most effective way of preventing
 Involves no introduction of chemical or pregnancy and STD.
foreign material into the body or sustaining
from sexual intercourse during a fertile period.  Those who chose abstinence should consider
having a backup method of contraception readily
 Disadvantage: any of the natural family planning available.
method doesn’t prevent STI and HIV from
acquiring.
Calendar Method
 Requires a couple to abstain from coitus on the days of menstrual cycle when the woman is most
likely to conceive (3 or 4 days before until 3 or 4 days after ovulation).

 To plan for this, the woman keeps a diary for six menstrual cycles.

 To calculate “safe” days, she substracts 18 from the shortest cycle documented (the 1st fertile day), and
 she substracts 11 from her longest cycle (last fertile day)

 Example: if she had six menstrual cycles ranging from 25 to 29 days, her fertile period would be from 7th day
(25-18) to the 18th day (29-11). A woman needs to avoid coitus during these days.

 Not reliable during: postpartum period, lactation, near menopause.

Basal Body Temperature
 Relies on slight changes in basal body temperature (woman’s body temperature at rest).

 Just before the day of ovulation, a woman BT falls about 0.5°F, and the time of ovulation, her BBT
rises full degree (0.4 to 0.8°F) because of the influence of progesterone.

 To use this method, the woman should take her temperature each morning immediately after waking before
she undertakes any activity.

 She refrains from sexual intercourse for the next 3 days as soon as she notices a slight dip in
temperature. Followed by an increase.

 Because sperm can survive for at least 4 days in the female reproductive tract, it is usually
recommended that the couple combine this method with a calendar method, so that they can abstain for a few
days before ovulation as well.

 Not reliable during: infection, intake of antipyretics, immunizations, alcohol ingestion, emotional upset, and
sleeplessness.

Cervical Mucus Method

 “Ovulation Method” or “Billing’s Method”

 Used to predict ovulation by using the changes in cervical mucus that normally occur with ovulation.

 Before ovulation, the cervical mucus is thick and does not stretch when pulled between the thumb and
finger.

 During ovulation, cervical mucus becomes copious, thin, watery, and transparent. It feels slippery and
stretches at least 1 inch before the strand breaks, a property known as Spinnbarkeit. The woman should
abstain from coitus during this time.

 Most useful for women who do not ovulate regularly.

Symptothermal Method
 Identifies fertile periods by a combination of signs and symptoms.

 The woman takes her temperature daily, analyzes her cervical mucus everyday and observes for other
signs of ovulation such as mittelschmertz (midcycle abdominal pain).
Coitus Interruptus
 Withdrawal Method - involves premature withdrawal of penis from the vagina before ejaculation.

 Probably the oldest type of birth control practiced.

 Reliability is low, because sperm are emitted or present in pre-ejaculation fluid.
Lactation Amenorrhea Method
 Exclusive breastfeeding for 3 months naturally suppresses ovulation process.

 Not reliable after 3 months of breastfeeding, when the infant is receiving a supplemental feeding or not
sucking well.

BARRIER METHODS
 are forms of birth control that work by the placement of a chemical or other barrier between the
cervix and advancing sperm so that sperm cannot enter the uterus or fallopian tubes and fertilize the ovum.
CHEMICAL BARRIERS
SPERMICIDE
 Is an agent that causes the death of spermatozoa before they can enter the cervix. They also
change the vaginal pH to a strong acid level, a condition not conducive form sperm survival.

 The gels, creams, sponges, films, foams, and suppositories are inserted into the vagina no more than 1 hour
before coitus for the most effective results.

 They should remain in place for 6 hours after intercourse to ensure sperm destruction.

 Examples: cocoa butter and glycerin-based vaginal suppositories, nonoxynol-9 and octoxynol.
 Contraindicated in women with acute cervicitis.

 Disadvantage: associated with candidiasis, and irritating to vagina and penis during coitus. They do not
protect against STDs.
MECHANICAL BARRIERS
 Block the entrance of sperm into the cervix
DIAPHRAGM
 Is a circular rubber disk that is placed over the cervic before intercourse.

 Is prescribed and fitted initially by a physician, nurse practitioner, or nurse-midwife to ensure a

correct fit.

 The diaphragm should be checked when:

 The woman gains or losses weight more than 15lbs.

 Pregnancy, miscarriage, elective termination of pregnancy

 Cervical surgery
 Should remain in place for at least 6 hours after intercourse.

 Should be washed in mild soap and water, dried gently, and stored in its protective case.

 Caution them not to accidentally tear the diaphragm with long or sharp fingernails.

 Contraindications
  History of toxic shock syndrome

 Allergy to rubber or spermicides

 History of recurrent UTIs

 Presence of acute cervicitis or a papillomavirus infection

 Prolapsed uterus, retroflexed, or anteflexed, cystocele, or rectolele

 Women over 35 have a higher incidence of cystocele or rectolele than younger women so diaphragms may
not be the ideal contraceptive.

 To prevent Toxic Shock Syndrome using a diaphragm, advise women to:

 Wash their hands thoroughly with a soap and water before insertion or removal.

 Do not use a diaphragm during a menstrual period.

 Do not leave a diaphragm in place longer than 24 hours.

 Be aware of the symptoms of TSS, such as elevated temperature, diarrhea, vomiting, muscle aches, and a
sun-burn-like rash.

 If symptoms of TSS should occur, immediately remove the diaphragm and call a health care provider.
CERVICAL CAPS
 Are made of soft rubber, are shaped like thimble with a thin rim, and fit snugly over the uterine cervix.

 The precautions for use are the same as for diaphragm use, except they can be kept in place longer.

 Cervical caps, like the diaphragm, must be fitted individually by a health care provider.

Contraindicated in a woman who has:

 An abnormally short or long cervix

 A previous abnormal Pap smear

 A history of TSS

 An allergy to latex or spermicide

 A history of pelvic inflammatory disease, cervicitis, or papillomavirus infection

 A history of cervical cancer

 An undiagnosed vaginal bleeding

MALE CONDOMS
 Is a latex rubber or synthetic sheath that is placed over the erect penis before coitus to trap sperm.
 Recommended for male who do not maintain a monogamous relationship.

 Advantage: they are one of the few “male responsibility” birth control measures available, nor health care
visit or prescription is needed. It prevents the spread of STD and HIV.

 Disadvantage: decreased sensation, the interruption of sexual foreplay to apply the condom, and the need to
quickly remove the penis from the vagina after ejaculation to remove the condom.
 Contraindication: senstivity to latex

 Reminder!
 A condom should be positioned so that it is loose enough at the penis tip to collect the ejaculate.

 The penis must be withdrawn before it begins to become flaccid after ejaculation. If not withdrawn, sperm
may leak from the now loosely fitting sheath into the vagina.
FEMALE CONDOM
 Are latex sheaths made of polyurethane ad pre-lubricated with a spermicide.
 The inner ring covers the cervix, and the outer ring rests against the vaginal opening.
 The sheath may be inserted any time before sexual intercourse begins and then removed after ejaculation
occurs.
 Advantage: it offers protection against pregnancy and infection.
 Disadvantage: expensive than male condoms, have not gained popularity because of their bulk and difficulty
in use.

Check for Understanding:

1. A nurse teaches a woman who wishes to become pregnant that if she assesses for spinnbarkeit she will be able to
closely predict her time of ovulation. Which technique should the client be taught to assess for spinnbarkeit?
A. Take her temperature each morning before rising.
B. Carefully feel her breasts for glandular development.
C. Monitor her nipples for signs of tingling and sensitivity.
D. Assess her vaginal discharge for elasticity and slipperiness.

2. In analyzing the need for teaching regarding sexual health in a client who is sexually active, which of the following
questions is the most important for a nurse to ask?
A. “How old are your children?”
B. “Did you have intercourse last evening?”
C. “With whom do you have intercourse?”
D. “Do you use vaginal lubricant?”

3. A client’s basal body temperature (BBT) chart for one full month is shown below. Based on the temperatures
shown, what can the nurse conclude?
A. It is likely that she has not ovulated.
B. The client’s fertile period is between 12 and 18 days.
C. The client’s period is abnormally long.
D. It is likely that her progesterone levels rose on day 15.

4. A nurse is educating a client who has been diagnosed with infertility on how to complete a basal body
temperature chart to determine her ovulation pattern. The client states, “I really don’t want to take my temperature
every day. Is there any other way to find out if and when I ovulate?”
A. “There are a number of other ways to determine ovulation, but they all require you to be examined by an
obstetrician every month.”
B. “A test you can do at home requires you to spit on a microscopic slide and then look at the slide under a
microscope.”
C. “You can test your vaginal discharge each day to determine when you should have intercourse because the
hormone progesterone is elevated. “
D. “Although there are some tests that you can perform at home, they all cost well over a hundred
dollars to purchase.”

5. A couple seeking contraception and infection-prevention counseling state, “We know that the best way for us to
prevent both pregnancy and infection is to use condoms plus spermicide every time we have sex.” Which of the
following is the best response by the nurse?
A. “That is correct. It is best to use a condom with spermicide during every sexual contact.”
B. “That is true, except if you have intercourse twice in one evening. Then you do not have to apply more
spermicide.”
C. “That is not true. It has been shown that condoms alone are very effective and that spermicide can
increase the transmission of some viruses.”
D. “That is not necessarily true. Spermicide has been shown to cause cancer in men and women who use it too
frequently.”

6. The nurse is teaching an uncircumcised male to use a condom. Which of the following information should be
included in the teaching plan?
A. Apply mineral oil to the tip and shaft of the condom-covered penis.
B. Pull back the foreskin before applying the condom.
C. Create a reservoir at the tip of the condom after putting it on.
D. Wait five minutes after ejaculating before removing the condom.

7. The nurse is teaching a young woman how to use the female condom. Which of the following should be included
in the teaching plan?
A. Reuse female condoms no more than five times.
B. Refrain from using lubricant because the condom may slip out of the vagina.
C. Wear both female and male condoms together to maximize effectiveness.
D. Remove the condom by twisting the outer ring and pulling gently.

8. A woman has a history of toxic shock syndrome. Which of the following forms of birth control should she be
taught to avoid?
A. Diaphragm.
B. Intrauterine device.
C. Birth control pills (estrogen-progestin combination).
D. Depo-Provera (medroxyprogesterone acetate).

9. During a counseling session on natural family planning techniques, how should the nurse explain the consistency
of cervical mucus at the time of ovulation?
A. It becomes thin and elastic.
B. It becomes opaque and acidic.
C. It contains numerous leukocytes to prevent vaginal infections.
D. It decreases in quantity in response to body temperature changes.
10. A client is being taught about the care and use of the diaphragm. Which of the following comments by the
woman shows that she understands the teaching that was provided?
A. “I should regularly put the diaphragm up to the light and look at it carefully.”
B. “This is one method that can be used during menstruation.”
C. “I can leave the diaphragm in place for a day or two.”
D. “The diaphragm should be well powdered before I put it back in the case.”