Jarvis ch. 27 - Female Genitourinary System

Question 1

During an examination, the nurse observes a female patient’s vestibule and expects to see the:

a. Urethral meatus and vaginal orifice
b. Vaginal orifice and vestibular (Bartholin’s) glands
c. Urethral meatus and paraurethral (Skene’s) glands
d. Paraurethral (Skene’s) and vestibular (Bartholin’s) glands

Answer 1

ANS: A
The labial structures encircle a boat-shaped space, or cleft, termed the vestibule. Within the vestibule are numerous openings. The urethral meatus and vaginal orifice are visible. The ducts of the paraurethral (Skene’s) glands and the vestibular (Bartholin’s) glands are present but not visible.

Question 2

During a speculum inspection of the vagina of a 25-year-old female who has never been pregnant, what would the nurse expect to see at the end of the vaginal canal?

a. Cervix with a smooth, small os
b. Pear-shaped uterus
c. Oval-shaped ovaries
d. Cervix with an irregular, enlarged os

Answer 2

ANS: A
At the end of the canal, the uterine cervix projects into the vagina. In nulliparous women, the cervix appears as a smooth, doughnut-shaped area with a small circular hole (the os). After childbirth, the os is slightly enlarged and irregular

Question 3

The uterus is usually positioned tilting forward and superior to the bladder. This position is known as:

a. Anteverted and anteflexed
b. Retroverted and anteflexed
c. Retroverted and retroflexed
d. Superiorverted and anteflexed

Answer 3

ANS: A
The uterus is freely movable, not fixed, and usually tilts forward and superior to the bladder (a position labelled as anteverted and anteflexed).

Question 4

An 11-year-old girl is in the clinic for her annual checkup. The nurse notices that she has begun to develop breasts, and during the conversation, the girl reveals that she is worried about her development. The nurse should use which of these techniques to best assist the young girl in understanding the expected sequence for development? The nurse should:

a. Use Tanner’s scale on the five stages of sexual development
b. Describe her development and compare it with that of other girls her age
c. Use Jacobsen’s table on expected development on the basis of height and weight data
d. Reassure her that her development is within normal limits and tell her not to worry about the next step

Answer 4

ANS: A
Tanner’s scale on the five stages of pubic hair development is helpful in teaching girls the expected sequence of sexual development

Question 5

A woman who is 8 weeks pregnant is in the clinic for a checkup. The nurse reads on her chart that her cervix is softened and looks cyanotic. The nurse knows that the woman is exhibiting __________ sign and __________ sign.

a. Tanner’s; Hegar’s
b. Hegar’s; Goodell’s
c. Chadwick’s; Hegar’s
d. Goodell’s; Chadwick’s

Answer 5

ANS: D
Shortly after the first missed menstrual period, the female genitalia show signs of the growing fetus. The cervix softens (Goodell’s sign) at 4 to 6 weeks, and the vaginal mucosa and cervix look cyanotic (Chadwick’s sign) at 8 to 12 weeks. These changes occur because of increased vascularity and edema of the cervix and hypertrophy and hyperplasia of the cervical glands. Hegar’s sign occurs when the isthmus of the uterus softens at 6 to 8 weeks. Tanner’s sign is not a correct response.

Question 6

When obtaining a sample for a Papanicolaou (“Pap”) test from a 60-year-old postmenopausal female patient, the nurse recognizes that the cervix is smaller and paler in response to:

a. Progesterone changes
b. Fibroid formations
c. Decreasing estrogen levels
d. Increasing vaginal secretions

Answer 6

ANS: C
Because cells in the reproductive tract are estrogen dependent, decreased estrogen levels during menopause bring dramatic physical changes. The cervix shrinks and looks paler, with a thick, glistening epithelium.

Question 7

The nurse is reviewing the changes that occur with menopause. Which changes are associated with menopause?

a. Uterine and ovarian atrophy, along with a thinning of the vaginal epithelium
b. Ovarian atrophy, increased vaginal secretions, and increasing clitoral size
c. Cervical hypertrophy, ovarian atrophy, and increased acidity of vaginal secretions
d. Vaginal mucosal fragility, increased acidity of vaginal secretions, and uterine hypertrophy

Answer 7

ANS: A
The uterus shrinks because of its decreased myometrium. The ovaries atrophy to 1 to 2 cm and are not palpable after menopause. The sacral ligaments relax, and the pelvic musculature weakens; consequently, the uterus droops. The cervix shrinks and looks paler with a thick, glistening epithelium. The vaginal epithelium atrophies, becoming thinner, drier, and itchy. The vaginal pH becomes more alkaline, and secretions are decreased, which results in a fragile mucosal surface that is at risk for vaginitis.

Question 8

A 54-year-old woman who has just completed menopause is in the clinic today for her yearly physical examination. Which of these statements should the nurse include in patient education? A postmenopausal woman:

a. “Is not at any greater risk for heart disease than a younger woman.”
b. “Should be aware that she is at increased risk for dyspareunia because of decreased vaginal secretions.”
c. “Has only stopped menstruating; there really are no other significant changes with which she should be concerned.”
d. “Is likely to have difficulty with sexual pleasure as a result of drastic changes in the female sexual response cycle.”

Answer 8

ANS: B

Decreased vaginal secretions leave the vagina dry and at risk for irritation and pain during intercourse (dyspareunia).

Question 9

A woman is in the clinic for an annual gynecological examination. The nurse should plan to begin the interview with the:

a. Menstrual history, because it is generally nonthreatening
b. Obstetric history, because it includes the most important information
c. Urinary system history, because problems may develop in this area as well
d. Sexual history, because discussing it first will build rapport

Answer 9

ANS: A
Menstrual history is usually nonthreatening and therefore a good topic with which to begin the interview. Obstetric, urinary, and sexual histories are also part of the interview but not necessarily the best topics to start the interview with

Question 10

A woman states that 2 weeks ago she had a urinary tract infection that was treated with an antibiotic. As a part of the interview, the nurse should ask, “Have you noticed any …”

a. “Changes in your urination patterns?”
b. “Excessive vaginal bleeding?”
c. “Unusual vaginal discharge or itching?”
d. “Changes in your desire for intercourse?”

Answer 10

ANS: C
Several medications may increase the risk for vaginitis. Broad-spectrum antibiotics alter the balance of normal flora, which may lead to the development of vaginitis.

Question 11

A 22-year-old woman has been considering using oral contraceptives. As a part of her health history, the nurse should ask:

a. “Do you have a history of heart murmurs?”
b. “Are you going to be in a monogamous relationship?”
c. “Have you carefully thought this choice through?”
d. “If you smoke, how many cigarettes do you smoke per day?”

Answer 11

ANS: D
Oral contraceptives, together with cigarette smoking, increase the risk for cardiovascular side effects. If cigarettes are used, then the nurse should assess the patient’s smoking history.

Question 12

When the nurse is interviewing a preadolescent girl, which opening question would be least threatening?

a. “Do you have any questions about growing up?”
b. “What has your mother told you about growing up?”
c. “When did you notice that your body was changing?”
d. “I remember being very scared when I got my first period. How do you think you’ll feel?”

Answer 12

ANS: C
Open-ended questions, such as, “When did you …?” rather than “Do you …?” should be asked. Open-ended questions are less threatening because they imply that the topic is normal and unexceptional.

Question 13

During the examination portion of a patient’s visit, she will be in the lithotomy position. Which of the following reflects some things that the nurse can do to make this position more comfortable for the patient?

a. Asking her to place her hands and arms over her head
b. Elevating her head and shoulders to maintain eye contact
c. Allowing her to choose to have her feet in the stirrups or have them resting side by side on the edge of the table
d. Allowing her to keep her buttocks approximately 6 inches from the edge of the table to prevent her from feeling as if she will fall off

Answer 13

ANS: B
The nurse should elevate the patient’s head and shoulders to maintain eye contact. The patient’s arms should be placed at her sides or across the chest. Placing her hands and arms over her head only tightens the abdominal muscles. The feet should be placed into the stirrups, knees apart, and buttocks at the edge of the examining table. The stirrups are placed such that the legs are not abducted too far

Question 14

The nurse has just completed an inspection of a nulliparous woman’s external genitalia. Which of these would be a description of a finding within normal limits?

a. Redness of the labia majora
b. Multiple nontender sebaceous cysts
c. Discharge that is foul smelling and irritating
d. Gaping and slightly shrivelled labia majora

Answer 14

ANS: B
No lesions should be noted, except for the occasional sebaceous cysts, which are yellowish 1-cm nodules that are firm, nontender, and often multiple. The labia majora are dark pink, moist, and symmetrical; redness indicates inflammation or lesions. Discharge that is foul smelling and irritating may indicate infection. In the nulliparous woman, the labia majora meet in the midline and are symmetrical and plump

Question 15

The advanced practice nurse is preparing for an examination of the internal genitalia of a woman. Which order of the examination is correct?

a. Bimanual, speculum, and rectovaginal
b. Speculum, rectovaginal, and bimanual
c. Speculum, bimanual, and rectovaginal
d. Rectovaginal, bimanual, and speculum

Answer 15

ANS: C
The correct sequence is the speculum examination; after removing the speculum, the bimanual examination is performed and then the rectovaginal examination. The examiner should change gloves before performing the rectovaginal examination to avoid spreading any possible infection.

Question 16

During an internal examination of a woman’s genitalia, the advanced practice nurse will use which technique for proper insertion of the speculum?

a. The woman is instructed to bear down, and the speculum blades are opened and applied in a swift, upward movement.
b. The blades of the speculum are inserted on a horizontal plane, turning them to a 30-degree angle while continuing to insert them. The woman is asked to bear down after the speculum is inserted.
c. The woman is instructed to bear down, the width of the blades is horizontally turned, and the speculum is inserted downward at a 45-degree angle toward the small of the woman’s back.
d. The blades are locked open by turning the thumbscrew. Once the blades are open, pressure is applied to the introitus, and the blades are inserted downward at a 45-degree angle to bring the cervix into view.

Answer 16

ANS: C
The examiner should instruct the woman to bear down, turn the width of the blades horizontally, and insert the speculum at a 45-degree angle downward toward the small of the woman’s back

Question 17

The nurse is examining a 35-year-old female patient. During the health history, the nurse learns that she has had two term pregnancies and that both times the babies were delivered vaginally. During the internal examination, the nurse observes that the cervical os is a horizontal slit with some healed lacerations and that the cervix has some nabothian cysts that are small, smooth, and yellow. In addition, the nurse notices that the cervical surface is granular and red, especially around the os. Finally, the nurse notices the presence of stringy, opaque, odourless secretions. Which of these findings are abnormal?

a. Nabothian cysts are present.
b. The cervical os is a horizontal slit.
c. The cervical surface is granular and red.
d. Stringy and opaque secretions are present.

Answer 17

ANS: C
Normal findings: Nabothian cysts may be present on the cervix after childbirth. The cervical os is a horizontal, irregular slit in the parous woman. Secretions vary according to the day of the menstrual cycle, and may be clear and thin or thick, opaque, and stringy. The surface is normally smooth, but cervical eversion, or ectropion, may occur where the endocervical canal is rolled out. Abnormal finding: The cervical surface being reddened or granular may indicate a lesion.

Question 18

A patient calls the clinic for instructions before undergoing a Pap test. The most appropriate instructions from the nurse are:

a. “If you are menstruating, please use pads to avoid anything being placed into the vagina.”
b. “Avoid intercourse, inserting anything into the vagina, or douching within 24 hours of your appointment.”
c. “If you suspect that you have a vaginal infection, please gather a sample of the discharge to bring with you.”
d. “We would like you to use a mild saline douche before your examination. You may pick this up in our office.”

Answer 18

ANS: B
When instructing a patient before the Pap smear is obtained, the nurse should follow these guidelines: Do not obtain a specimen during the woman’s menses or if a heavy infectious discharge is present. Instruct the woman not to douche, have intercourse, or put anything into the vagina within 24 hours before collecting the specimens. Any specimens will be obtained during the visit, not beforehand.

Question 19

During an examination, which tests will the nurse collect to screen for cervical cancer?

a. Endocervical specimen, cervical scrape, and vaginal pool
b. Endocervical specimen, vaginal pool, and acetic acid wash
c. Endocervical specimen, potassium hydroxide (KOH) preparation, and acetic acid wash
d. Cervical scrape, acetic acid wash, saline mount (“wet prep”)

Answer 19

ANS: A
Laboratories may vary in method, but usually the test consists of three specimens: endocervical specimen, cervical scrape, and vaginal pool. The other tests (acetic acid wash, KOH preparation, and saline mount) are used to test for STIs

Question 20

When performing the bimanual examination, the advance practice nurse notices that the cervix feels smooth and firm, is round, and is fixed in place. When cervical palpation is performed, the patient complains of some pain. The nurse’s interpretation of these results should be which of these?

a. These findings are all within normal limits.
b. Cervical consistency should be soft and velvety, not firm.
c. The cervix should move when palpated; an immobile cervix may indicate malignancy.
d. Pain may occur during palpation of the cervix.

Answer 20

ANS: C
Normally, the cervix feels smooth and firm, similar to the consistency of the tip of the nose. It softens and feels velvety at 5 to 6 weeks of pregnancy (Goodell’s sign). The cervix should be evenly rounded. With a finger on either side, the examiner should be able to move the cervix gently from side to side, and doing so should produce no pain for the patient. Hardness of the cervix may occur with malignancy. Immobility may occur with malignancy, and pain may occur with inflammation or ectopic pregnancy

Question 21

The advance practice nurse is palpating a female patient’s adnexa. The findings include a firm, smooth uterine wall; and the ovaries are palpable and feel smooth and firm. The fallopian tube is firm and pulsating. The nurse’s most appropriate course of action would be to:

a. Tell the patient that her examination is normal
b. Give her an immediate referral to a gynecologist
c. Suggest that she return in a month for a recheck to verify the findings
d. Tell the patient that she may have an ovarian cyst that should be evaluated further

Answer 21

ANS: B
Normally, the uterine wall feels firm and smooth, with the contour of the fundus rounded. Ovaries are not often palpable, but when they are, they normally feel smooth, firm, and almond shaped and are highly movable, sliding through the fingers. The fallopian tube is not normally palpable. No other mass or pulsation should be felt. Pulsation or palpable fallopian tube suggests ectopic pregnancy, which warrants immediate referral.

Question 22

A 35-year-old transgender woman is in the office for routine gynecological care. She had a vaginoplasty 12 months ago. Which of the following does the nurse know to be true regarding this visit?

a. Her cervical mucosa will be red and dry looking.
b. The patient should have a Pap test every 2 years.
c. The nurse will adhere to the cervical screening guidelines for women.
d. The nurse knows that cervical screening is not appropriate.

Answer 22

ANS: D
Transgender women who have undergone vaginoplasty do not have a cervix; therefore cervical screening is not appropriate for them. For transgender men, follow cervical cancer screening guidelines for non–transgender women if the cervix is present

Question 23

The nurse is preparing to examine the external genitalia of a school-age girl. Which position would be most appropriate in this situation?

a. In the parent’s lap
b. In a frog-leg position on the examining table
c. In the lithotomy position with the feet in stirrups
d. Lying flat on the examining table with legs extended

Answer 23

ANS: B
For school-age children, placing them on the examining table in a frog-leg position is best. With toddlers and preschoolers, having the child on the parent’s lap in a frog-leg position is best

Question 24

During a vaginal examination of a 38-year-old woman, the nurse notices that the vulva and vagina are erythematous and edematous, with thick, white, curdlike discharge adhering to the vaginal walls. The woman reports intense pruritus and thick white discharge from her vagina. The nurse knows that these history and physical examination findings are most consistent with which condition?

a. Candidiasis
b. Trichomoniasis
c. Atrophic vaginitis
d. Bacterial vaginosis

Answer 24

ANS: A
The woman with candidiasis often reports intense pruritus and thick white discharge. The vulva and vagina are erythematous and edematous. The discharge is usually thick, white, and curdlike. Infection with trichomoniasis causes a profuse, watery, grey-green, and frothy discharge. Bacterial vaginosis causes a profuse discharge that has a “foul, fishy, rotten” odour. Atrophic vaginitis may have a mucoid discharge

Question 25

A 22-year-old woman is being seen at the clinic for problems with vulvar pain, dysuria, and fever. On physical examination, the nurse notices clusters of small, shallow vesicles with surrounding erythema on the labia. Inguinal lymphadenopathy present is also present. The most likely cause of these lesions is:

a. Pediculosis pubis
b. Contact dermatitis
c. HPV infection
d. Herpes simplex virus type 2 infection

Answer 25

ANS: D
Herpes simplex virus type 2 infection manifests as clusters of small, shallow vesicles, with surrounding erythema erupting on the genital areas. Inguinal lymphadenopathy is also present. The woman reports local pain, dysuria, and fever

Question 26

A 46-year-old woman is in the clinic for her annual gynecological examination. She voices her concern about ovarian cancer because her mother and sister had died as a result of it. Which statement regarding ovarian cancer does the nurse know to be correct?

a. Ovarian cancer rarely has any symptoms.
b. The Pap test detects the presence of ovarian cancer.
c. Women at high risk for ovarian cancer should undergo screening with annual transvaginal ultrasonography.
d. Women over age 40 years should have a thorough pelvic examination every 3 years.

Answer 26

ANS: C
With ovarian cancer, the patient may have abdominal pain, pelvic pain, increased abdominal size, bloating, and nonspecific gastrointestinal symptoms; or she may be asymptomatic. The Pap test does not detect the presence of ovarian cancer. Annual transvaginal ultrasonography may detect ovarian cancer at the early stage in women who are at high risk

Question 27

During bimanual examination, the advance practice nurse detects a solid tumour on the ovary, which is heavy and fixed and has a poorly defined mass. This finding is suggestive of:

a. Ovarian cyst
b. Endometriosis
c. Ovarian cancer
d. Ectopic pregnancy

Answer 27

ANS: C
Ovarian tumours that are solid, heavy, fixed and poorly defined masses are suggestive of malignancy. Benign masses may feel mobile and solid. An ovarian cyst may feel smooth, round, fluctuant, mobile, and nontender. With an ectopic pregnancy, the examiner may feel a palpable, tender pelvic mass that is solid, mobile, and unilateral. In endometriosis, there may be masses (in various locations in the pelvic area) that are small, firm, nodular, and tender to palpation, and the ovaries will be enlarged

Question 28

A 25-year-old woman comes to the emergency department with a sudden fever of 38.3°C and abdominal pain. During the examination, the nurse notices that the patient has rigid, boardlike lower abdominal musculature. When the nurse tries to perform a vaginal examination, the patient experiences severe pain when the uterus and cervix are moved. The nurse knows that these signs and symptoms are suggestive of:

a. Endometriosis
b. Uterine fibroids
c. Ectopic pregnancy
d. Pelvic inflammatory disease

Answer 28

ANS: D

These signs and symptoms are suggestive of acute pelvic inflammatory disease, also known as acute salpingitis

Question 29

During examination of the external genitalia of a woman, the nurse notices several lesions around the vulva. The lesions are pink, moist, soft, and pointed papules. The patient states that she is not aware of any problems in that area. The nurse recognizes that these lesions may be:

a. Syphilitic chancre
b. Herpes simplex virus type 2 (herpes genitalis) lesions
c. HPV or genital warts
d. Pediculosis pubis (crab lice)

Answer 29

ANS: C
HPV lesions are painless, warty growths that the woman may not notice. Lesions are pink or flesh coloured, soft, pointed, moist, warty papules that occur in single or multiple cauliflowerlike patches around the vulva, introitus, anus, vagina, or cervix. Herpetic lesions are painful clusters of small, shallow vesicles with surrounding erythema. Syphilitic chancres begin as a solitary silvery papule that erodes into a red, round or oval superficial ulcer with a yellowish discharge. Pediculosis pubis causes severe perineal itching and excoriations and erythematous areas

Question 30

A woman has just been diagnosed with HPV infection, or genital warts. The nurse should counsel her to receive regular examinations because this virus places her at a higher risk for __________ cancer.

a. Uterine
b. Cervical
c. Ovarian
d. Endometrial

Answer 30

ANS: B

HPV is the virus responsible for most cases of cervical cancer, not the other cancers.

Question 31

During an internal examination, the nurse notices that the cervix bulges outside the introitus when the patient is asked to strain. The nurse will document this as:

a. Uterine prolapse, graded first degree
b. Uterine prolapse, graded second degree
c. Uterine prolapse, graded third degree
d. A normal finding

Answer 31

ANS: B
The cervix should not be found to bulge into the vagina. Uterine prolapse is graded as follows: first degree—the cervix appears at the introitus with straining; second degree—the cervix bulges outside the introitus with straining; and third degree—the whole uterus protrudes, even without straining (essentially, the uterus is inside out)

Question 32

A 35-year-old woman is at the clinic for a gynecological examination. During the examination, she asks the nurse, “How often do I need to have this Pap test done?” Which reply by the nurse is correct?

a. “It depends. Do you smoke?”
b. “A Pap test needs to be performed annually until you are 65 years of age.”
c. “If you have two consecutive normal Pap tests, then you can wait 5 years between tests.”
d. “Between 25 to 69 years, screening every 3 years is recommended.”

Answer 32

ANS: D
• Women under the age of 25 years: routine Pap test screening is no longer recommended.
• Women and transgender individuals with a cervix, ages 25 to 69 years: screening every 3 years with cervical cytology is recommended.
• Women age 70 years and older: screening with cervical cytology every 3 years is recommended if previous screening was inadequate and until three negative results have been received; otherwise, screening may stop. More frequent testing may be considered for women at high risk. Women who have received the HPV vaccine should still take part in the currently recommended cervical cancer screening programs.

Question 33

The advance practice nurse is palpating an ovarian mass during an internal examination of a 63-year-old woman. Which findings of the mass’s characteristics would suggest the presence of an ovarian cyst? (Select all that apply.)

a. Heavy and solid
b. Mobile and fluctuant
c. Mobile and solid
d. Fixed
e. Smooth and round
f. Poorly defined

Answer 33

ANS: B, E
An ovarian cyst (fluctuant ovarian mass) is usually asymptomatic and would feel like a smooth, round, fluctuant, mobile, nontender mass on the ovary. A mass that is heavy, solid, fixed, and poorly defined suggests malignancy. A benign mass may feel mobile and solid