Abdomen and pelvisHigh yield
Adrenal glands
Two small glands, one perched on top of each kidney, whose outer layer makes cortisol and aldosterone and whose core makes adrenaline.
Why the exam cares
Cortisol is the stress hormone that holds blood pressure and blood sugar up, and a patient who lacks it, or whose steroid pills stopped suddenly, can collapse into shock. The NCLEX tests adrenal crisis recognition and the steroid teaching that prevents it.
- Sit high in the back of the abdomen behind the peritoneum, capping the upper pole of each kidney at about the level of the lowest ribs.
- Too deep to palpate; the nurse assesses them through blood pressure, sodium, potassium, glucose, and skin changes.
A patient with adrenal insufficiency who meets a stressor (surgery, infection, or abruptly stopped steroids) develops profound hypotension, weakness, vomiting, low sodium, high potassium, and low glucose. The nurse gives IV hydrocortisone and fluids as ordered without waiting for lab confirmation, because the shock will not respond to fluids alone, and treats the high potassium and low glucose.
Too little (Addison): weight loss, fatigue, low blood pressure, salt craving, bronze darkening of the skin, low sodium, high potassium, low glucose. Too much (Cushing, or long-term steroids): round face, fat on the upper back, thin bruising skin, muscle wasting, high blood sugar, high blood pressure, low potassium, and poor infection resistance. For Addison the nurse checks orthostatic blood pressures, pushes salt and fluids, and never lets a steroid dose be skipped, because the patient has no reserve. For Cushing the nurse checks glucose, handles skin gently, keeps infection precautions strict since the fever response is blunted, and watches for fractures because bone thins.
Never stop steroids suddenly; the adrenals have shut down and need time to restart, so doses are tapered. Take them in the morning with food, expect higher doses during illness or surgery, carry medical identification, and report signs of infection early because steroids hide the fever.
A tumor of the adrenal core dumps adrenaline in bursts, causing severe headache, sweating, palpitations, and dangerously high blood pressure. Pressing on the abdomen can trigger a surge that ends in stroke or heart attack, so the nurse avoids deep abdominal palpation, keeps the room calm, and monitors blood pressure closely.
Pharmacological and Parenteral TherapiesPhysiological AdaptationReduction of Risk Potential
Abdomen and pelvisHigh yield
Appendix
A finger-sized, blind-ended tube hanging off the cecum, the first part of the large intestine, in the right lower abdomen.
Why the exam cares
NCLEX treats appendicitis as a safety and priority problem: the nurse must know which comfort measures are unsafe because they can rupture the appendix, and that pain which suddenly stops is a warning, not good news. McBurney's point is what lets the nurse spot the pattern early.
- McBurney's point sits about one-third of the way along a line from the bony point at the front of the right hip (the anterior superior iliac spine) to the umbilicus.
- It arises from the cecum in the right lower quadrant, just below where the small bowel joins the colon.
- Its tip varies: most often it lies tucked behind the cecum, and next most often it hangs down into the pelvis, so pain can sit higher, lower, or deeper than expected.
The classic story is vague pain around the umbilicus that moves over several hours to settle at McBurney's point, with low-grade fever, nausea, and loss of appetite. The nurse asks where the pain started and where it is now, palpates the right lower quadrant gently and last, and reports localized tenderness there to the provider, because that migration plus point tenderness is what raises suspicion for appendicitis.
Pressing slowly on the right lower quadrant and releasing quickly causes a sharp jolt of pain if the peritoneum is inflamed. The nurse tests it once, at the end of the exam, because it hurts and repeating it adds nothing. Right lower quadrant pain when the left lower quadrant is pressed (Rovsing's sign), or when the right hip is extended or flexed against resistance (psoas sign), points the same way.
The nurse keeps the patient NPO because surgery is likely, and never applies heat or gives laxatives or enemas: heat increases blood flow to the inflamed appendix, and laxatives and enemas stimulate the bowel, so both can make it burst. Sudden relief of pain followed by a rigid, board-like abdomen, fever, and a rising pulse means rupture and peritonitis. The nurse reports it immediately, places the patient in semi-Fowler's so infected fluid collects low in the pelvis instead of spreading upward, watches for sepsis, and expects IV antibiotics and urgent surgery.
Reduction of Risk PotentialPhysiological Adaptation
Abdomen and pelvisHigh yield
Bladder
A hollow muscular bag in the pelvis behind the pubic bone that stores urine and stretches upward into the abdomen as it fills.
Why the exam cares
A bladder that cannot empty rises out of the pelvis where the nurse can feel it, and in a spinal cord patient it can trigger a hypertensive crisis. The NCLEX asks the nurse to find retention, measure it without a catheter first, and prevent the infection that catheters bring.
- Sits low behind the pubic symphysis; empty, the adult bladder is entirely inside the pelvis and cannot be felt.
- Full, it rises as a smooth, round, firm mass above the pubic bone toward the umbilicus, dull to percussion.
- Lies in front of the rectum and, in women, in front of the uterus, which is why a full bladder pushes the postpartum uterus up and to the side.
The nurse palpates gently from the umbilicus down toward the pubic bone; a firm rounded mass with an urge to void when pressed means retention. A patient who has not voided within about six to eight hours after surgery or catheter removal, or who dribbles small amounts often, is checked before the bladder overstretches.
A portable ultrasound over the pubic bone measures the volume left after voiding without any risk of infection. The nurse scans before choosing to catheterize and uses the result, along with the facility's threshold, to decide whether a straight catheterization is needed.
The nurse secures the catheter to the thigh (or the lower abdomen in a man), keeps the drainage bag below the bladder and off the floor, keeps tubing free of dependent loops that trap urine, cleans the perineum and the first few inches of catheter daily with soap and water, and never disconnects the closed system. The best prevention is removal: the nurse questions every day whether the catheter is still needed.
In a patient with an injury at T6 or above, a distended bladder from a blocked or kinked catheter is the most common trigger of autonomic dysreflexia. At a sudden pounding headache and soaring blood pressure the nurse first sits the patient upright and lowers the legs to bring the pressure down, then goes straight to the bladder: unkink or flush the catheter, or catheterize if there is none, before checking the bowel or skin.
Safety and Infection ControlBasic Care and ComfortPhysiological Adaptation
Abdomen and pelvisHigh yield
Kidneys
Two bean-shaped organs on the back wall of the abdomen, one on each side of the spine, that filter the blood and make urine.
Why the exam cares
Urine output is the nurse's quickest bedside check on kidney perfusion, and a kidney that stops filtering lets potassium rise toward a fatal rhythm. The nurse tracks output, checks the catheter before calling, watches for bleeding after a biopsy, and acts on a rising potassium.
- They lie behind the peritoneum, against the back muscles, from about the twelfth thoracic to the third lumbar vertebra; the right sits a little lower because the liver is above it.
- The costovertebral angle is the notch where the twelfth rib meets the spine on each side of the back; the kidney lies just beneath it.
- Usually not palpable in adults, though the lower pole of the right kidney may be felt in a thin person; an adrenal gland sits on top of each kidney.
The nurse lays one palm flat over the costovertebral angle and strikes it gently with the other fist; pain there points to the kidney rather than the bladder. With fever, chills, and nausea the nurse suspects pyelonephritis and collects the urine culture before the first antibiotic dose, because antibiotics can make the culture unreliable. With severe, colicky pain spreading toward the groin the nurse suspects a stone, gives the ordered pain medicine, encourages fluids unless restricted, and strains every void to catch the stone for analysis.
Adults should make at least about 0.5 mL/kg an hour, about 30 mL an hour for an average-sized adult; output that stays below that floor means the kidneys are underperfused or injured. Before calling, the nurse checks that the catheter is not kinked, clamped, or blocked and that the bladder is not full, because a blocked tube can look like failing kidneys. The nurse then reports the output with the blood pressure and any recent contrast dye, NSAIDs, or aminoglycosides.
The kidney has a rich blood supply, so the nurse checks clotting studies and platelets beforehand and confirms blood thinners were held as ordered. The patient lies face down with a pillow under the abdomen and holds a breath as the needle goes in, so the kidney does not move. Afterward the patient stays on bed rest as ordered with frequent vital signs, and the nurse checks each void: some blood in the first 24 hours is common and should lighten, but bleeding that gets heavier, passes clots, lasts past 24 hours, or comes with flank pain, dizziness, a fast pulse, or falling blood pressure is reported at once.
When filtering falls, potassium is not excreted and climbs. The ECG shows tall, peaked T waves first, then a longer PR interval, a flattening P wave, and a widening QRS that can end in a lethal rhythm. The nurse follows potassium levels, holds potassium-containing IV fluids and supplements, teaches the patient to avoid salt substitutes (potassium chloride), places the patient on a cardiac monitor, and reports a high level with ECG changes immediately.
Reduction of Risk PotentialPhysiological Adaptation
Abdomen and pelvisHigh yield
Large intestine and rectum
The last part of the digestive tract, running from the cecum in the right lower quadrant around the edge of the abdomen as the colon and down into the rectum and anal canal in the pelvis.
Why the exam cares
The colon's path tells the nurse where to start listening, what a colostomy's output should look like, and why a patient lies on the left side for an enema. The exam then asks the nurse to act: report a dusky stoma at once, and stop a disimpaction when the pulse drops.
- The cecum and appendix sit in the right lower quadrant, near McBurney's point, about one-third of the way from the right anterior superior iliac spine to the umbilicus.
- The ascending colon runs up the right flank to the liver, the transverse colon crosses the upper abdomen below the liver and stomach, and the descending colon runs down the left flank from the spleen.
- The sigmoid colon sits in the left lower quadrant, where hard stool can often be felt in a constipated patient.
- The rectum lies in the back of the pelvis against the sacrum and coccyx, behind the bladder, and in women also behind the uterus and vagina.
The nurse inspects, then auscultates, then percusses and palpates, because touching the abdomen first can change the bowel sounds. Listening starts in the right lower quadrant over the ileocecal valve, where sounds are normally present, and covers all four quadrants. High-pitched rushes can signal early obstruction, and sounds are called absent only after about 5 minutes in each quadrant with nothing heard.
A healthy stoma is pink to red and moist; a dusky, purple, or black stoma means its blood supply is failing, so the nurse reports it to the surgeon at once. Output follows the segment: liquid from an ascending colostomy, mushy from a transverse one, and formed from a descending or sigmoid one, which can be irrigated to set a schedule. The nurse empties the pouch when it is one-third to one-half full so the weight does not break the seal.
The nurse positions the patient on the left side, because the sigmoid and descending colon lie on the left and the fluid flows in with gravity. The lubricated tip goes in about 3 to 4 inches in an adult. If cramping starts, the nurse lowers the bag or pauses the flow until it eases.
Liquid stool seeping around a hard mass, with cramping and a full rectum, points to impaction in a constipated or bedbound patient. Digital removal needs a prescription and can stimulate the vagus nerve and slow the heart, so the nurse checks the pulse before and during it and stops if the patient becomes bradycardic, dizzy, or pale. Prevention is fluids, fiber, activity, and a regular toileting time.
Basic Care and ComfortReduction of Risk Potential
Abdomen and pelvisHigh yield
Liver
The largest internal organ, lying under the right ribs and diaphragm, which filters blood from the gut, makes clotting factors and albumin, clears ammonia and drugs, and makes bile.
Why the exam cares
Exam questions test what the nurse does when the liver stops doing its jobs. That means checking clotting studies before a liver biopsy or paracentesis, tracking weight and girth in ascites, titrating lactulose to stools, and timing the acetaminophen level and antidote.
- Sits in the right upper quadrant under the right ribs and diaphragm, with the smaller left lobe reaching across the midline into the epigastrium.
- The lower edge lies at or just below the right costal margin; the nurse feels for it under the margin as the patient breathes in deeply, because the diaphragm pushes the liver down.
- Percussion in the right midclavicular line gives dullness from about the fifth intercostal space to the costal margin; a span of about 6 to 12 cm is normal.
- An edge felt well below the ribs may mean enlargement, or a normal liver pushed down by hyperinflated lungs, as in COPD; the percussed span tells the two apart, and a hard, nodular, or tender edge suggests disease.
Before the procedure the nurse confirms PT/INR and platelet results and teaches the patient to exhale and hold the breath while the needle goes in, so the liver stays still. Afterward the patient lies on the right side with a small pillow under the rib margin for as long as facility policy sets, so body weight presses the puncture site against the chest wall. The liver is very vascular, so the nurse checks vital signs often; mild soreness or right shoulder pain is common, but a rising pulse, falling blood pressure, or severe or worsening abdominal or shoulder pain is reported at once as possible bleeding.
Scarring blocks blood flow from the gut into the liver, so fluid leaks into the abdomen and blood backs up into fragile esophageal varices. The nurse weighs the patient daily and measures abdominal girth at the same marked spot, has the patient empty the bladder before paracentesis, and watches blood pressure afterward because removing a large volume of fluid can drop it. Vomiting blood in a patient with cirrhosis is treated as a variceal bleed until proven otherwise, and it is more dangerous because the scarred liver makes fewer clotting factors.
A failing liver cannot clear ammonia, which builds up and causes confusion, drowsiness, and asterixis, a flapping tremor of the outstretched hands. The nurse gives lactulose and titrates it to about two or three soft stools a day, because it carries ammonia out in the stool; too many stools cause dehydration and low potassium, and both make the confusion worse. The nurse tracks level of consciousness and questions sedative orders, because a failing liver clears these drugs slowly and they hide changes in mental status.
The maximum for a healthy adult is 4 grams a day, lower with regular alcohol use or liver disease, and the nurse teaches patients to count the acetaminophen hidden in combination products; in overdose a toxic breakdown product builds up and kills liver cells, often while the patient still looks well. The acetaminophen level is drawn at least 4 hours after ingestion, because earlier levels cannot guide treatment, and the nurse gives acetylcysteine as ordered as early as possible, ideally within 8 hours. Patients taking drugs that can harm the liver are taught to report dark urine, pale stools, yellow skin or eyes, and right upper quadrant pain.
Physiological AdaptationReduction of Risk PotentialPharmacological and Parenteral Therapies
Abdomen and pelvisHigh yield
Ovaries and fallopian tubes
Two almond-shaped ovaries sit low in the pelvis, one on each side of the uterus, and each makes hormones and releases an egg that a fallopian tube catches and carries toward the uterus.
Why the exam cares
One-sided lower abdominal pain in any patient who could be pregnant needs a pregnancy test, because a pregnancy growing in the tube can rupture it and bleed into the abdomen where the bleeding cannot be seen. When the nurse finds shoulder-tip pain, a rising pulse, and a falling blood pressure, the nurse treats it as hemorrhage and acts first.
- In the lower pelvis on either side of the uterus: each ovary rests in a shallow hollow on the pelvic sidewall, and each tube runs out from the upper corner of the uterus toward its ovary.
- The widest part of the tube, the ampulla, is where fertilization normally happens and where most ectopic pregnancies implant.
- On a bimanual pelvic exam this area is called the adnexa. Normal tubes cannot be felt and normal ovaries often cannot, so a mass or tenderness on one side is a finding to report.
- Pain from a tube or ovary is felt in the right or left lower quadrant; on the right it is easily mistaken for appendicitis.
A missed period, one-sided lower abdominal pain, and spotting in a patient of childbearing age mean ectopic pregnancy until a pregnancy test and ultrasound rule it out. Sudden sharp pain, pain in the shoulder, dizziness, a fast pulse, and falling blood pressure mean the tube has ruptured and she is bleeding inside: the nurse starts two large-bore IVs, sends a type and crossmatch, keeps her NPO, and prepares her for surgery. An Rh-negative patient needs Rh immune globulin.
A stable patient with an early, unruptured ectopic may be given IM methotrexate, which stops the pregnancy tissue from growing. The nurse teaches her to avoid alcohol, folic acid supplements, and NSAIDs during treatment, and to return for hCG levels until they are undetectable. She must come back right away for worse pain, dizziness, or shoulder pain, because the tube can still rupture while the drug works.
Infection that climbs from the cervix into the uterus and tubes causes lower abdominal pain, fever, abnormal discharge, and pain when the cervix is moved on exam. The nurse gives antibiotics on schedule, places the patient in semi-Fowler's position to help drainage stay low in the pelvis, and teaches her to finish every dose and have partners treated. Untreated PID can form an abscess, and scarred tubes raise the risk of ectopic pregnancy and infertility.
An egg is released about 14 days before the next period and can be fertilized for roughly 12 to 24 hours, while sperm can survive for up to about 5 days. The nurse teaches this fertile window for both planning a pregnancy and avoiding one. A brief one-sided ache at mid-cycle (mittelschmerz) is normal ovulation pain.
Physiological AdaptationPharmacological and Parenteral TherapiesHealth Promotion and Maintenance
Abdomen and pelvisHigh yield
Pancreas
A long, flat gland lying sideways behind the stomach at the back of the upper abdomen, with its head in the curve of the duodenum and its tail reaching the spleen.
Why the exam cares
Its islet cells make insulin and glucagon, so it sits under every DKA and hypoglycemia item; its digestive enzymes cause acute pancreatitis when they switch on inside the gland. On the exam the nurse must spot the pain pattern, track lipase, rest the gland, and catch hypovolemia, hemorrhage, and low calcium before they turn into shock or tetany.
- Sits deep in the epigastrium and left upper quadrant, so the nurse cannot feel it; a soft, normal-feeling exam does not rule out pancreatitis.
- Lies behind the stomach, in front of the aorta and spine, which is why pancreatic pain goes straight through to the back.
- Its head fills the C-shaped curve of the duodenum, where the common bile duct joins the pancreatic duct, so a gallstone stuck there can block drainage and trigger pancreatitis.
- Its body crosses in front of the left kidney, and its tail reaches the spleen under the left ribs.
Watch for severe epigastric pain that goes through to the back, often after heavy drinking or a large fatty meal, with nausea, vomiting, and a tender, guarded abdomen. The nurse tracks serum lipase, which is more specific than amylase and stays high longer, and checks blood glucose because inflamed islet cells may not release enough insulin.
Keep the patient NPO so food does not stimulate enzyme release, use an NG tube to low suction if ordered for vomiting or ileus, and give IV fluids as ordered because large amounts of fluid leak out of the blood vessels. Report low blood pressure, a fast heart rate, or urine output under about 30 mL/hr, and watch breathing closely, since these patients can develop lung injury. Position side-lying with knees drawn up or sitting leaning forward to ease pain, and keep pain controlled so the patient can breathe deeply.
Bluish bruising around the umbilicus (Cullen's sign) or on the flanks (Grey Turner's sign) points to bleeding behind the abdominal lining: report it at once and watch for shock. Lipase digests the fat around the gland, and the freed fatty acids bind calcium, so the nurse checks for a hand spasm under an inflated blood pressure cuff (Trousseau's sign) or a facial twitch when the cheek is tapped (Chvostek's sign) and reports either one right away.
Thick mucus blocks the pancreatic ducts, so the child cannot absorb fat and has bulky, greasy, foul-smelling stools. The nurse gives pancreatic enzymes at the start of every meal and snack so they are in the gut with the food. For a child who cannot swallow capsules, open them and sprinkle the beads on a little acidic soft food such as applesauce, never crushed or chewed, then check the mouth for leftover beads and chart stool number and character, because the dose is adjusted to them.
Physiological AdaptationReduction of Risk PotentialPharmacological and Parenteral Therapies
Abdomen and pelvisHigh yield
Penis, testes, and scrotum
The external male genitals: the penis carries the urethra, and the two testes hang in the scrotum below it, outside the body so they stay cooler than core temperature.
Why the exam cares
Two of the most-tested bedside procedures happen here: passing a urinary catheter through the male urethra and caring for a newborn after circumcision. The exam asks the steps in order, and it also expects the nurse to recognize sudden scrotal pain as an emergency rather than something to watch.
- The urethral opening (meatus) sits at the tip of the glans; in an uncircumcised patient the foreskin must be pulled back to see it.
- The male urethra is long and curved, roughly 8 inches, and passes through the prostate just below the bladder, which is where a catheter often meets resistance.
- Each testis is palpated as a smooth, firm, oval body inside the scrotum; the soft, cord-like epididymis rides along its back edge and is normal to feel.
- The left testis usually hangs a little lower than the right.
The nurse retracts the foreskin, cleans the meatus, holds the penis upright at about 90 degrees to straighten the urethra, and inserts the lubricated catheter about 6 to 8 inches until urine flows, then advances it another inch or two before inflating the balloon so the balloon sits in the bladder and not the urethra. The nurse never forces past resistance at the prostate, and always pulls the foreskin back over the glans when done; a foreskin left retracted swells and traps the glans (paraphimosis), which is a urologic emergency.
The nurse checks the site with each diaper change, expects a yellow crust or exudate for the first few days as normal healing, and reports bleeding larger than a quarter-sized spot or no urine within 6 to 8 hours. A petroleum gauze dressing goes on a clamp (Gomco or Mogen) circumcision but never over a Plastibell, whose plastic ring is left to fall off on its own in about a week. A baby with hypospadias, where the meatus opens on the underside of the penis, is not circumcised because the surgeon needs that foreskin for the repair.
Sudden, severe one-sided scrotal pain with swelling, nausea, and a testis that sits high or sideways means the cord has twisted and cut off its own blood supply. The nurse treats this as a surgical emergency and gets the patient to the provider now, because the testis dies within hours without detorsion; this is not an infection to observe with ice and antibiotics.
A testis the nurse cannot feel in the scrotum of an infant (cryptorchidism) usually descends on its own in the first months; if it has not by about 6 months, the child is referred for surgery, because an undescended testis raises the risk of infertility and testicular cancer later. The nurse teaches males ages 15 to 35 to check both testes monthly after a warm shower, rolling each between the fingers, and to report any painless lump or change in size right away.
Reduction of Risk PotentialHealth Promotion and Maintenance
Abdomen and pelvisHigh yield
Peritoneum
The peritoneum is the thin serous membrane that lines the abdominal wall (parietal layer) and covers most abdominal organs (visceral layer), with a film of lubricating fluid in the space between them.
Why the exam cares
The parietal layer shares its nerves with the abdominal wall, so when it is inflamed the pain is sharp and the abdomen guards and turns rigid. A rigid, silent abdomen is a finding the nurse reports right away, and the same membrane is the filter in peritoneal dialysis, where sterile technique and watching the drainage protect the patient.
- The parietal layer lines the inside of the abdominal wall from the diaphragm down into the pelvis; the visceral layer covers the stomach, most of the intestines, most of the liver, and the spleen.
- The kidneys, pancreas, adrenal glands, and most of the duodenum sit behind it (retroperitoneal), which is why pancreatic and kidney pain is often felt in the back or flank.
- A peritoneal dialysis catheter is tunneled through the lower abdominal wall, and its tip rests low in the pelvis, where fluid collects when the patient sits or stands.
Look for severe abdominal pain, a board-like rigid abdomen, rebound tenderness, absent or faint bowel sounds, fever, a fast pulse, and shallow breathing in a patient who lies still with knees drawn up. The nurse reports these at once, keeps the patient NPO, expects an NG tube to suction, IV fluids, and antibiotics, and places the patient in semi-Fowler position to ease breathing and help fluid collect low in the pelvis. Fluid shifts into the abdomen and infection spreads to the blood, so the nurse watches for falling blood pressure and rising heart rate.
Dialysate warmed to body temperature runs in by gravity, dwells while wastes and water cross the membrane, then drains by gravity. The nurse uses strict aseptic technique with every connection and compares outflow with inflow, because outflow less than inflow means fluid is being retained. If drainage is slow, the nurse checks for kinks and closed clamps, keeps the bag below the abdomen, and turns the patient; cloudy drainage is often the earliest sign of peritonitis and is reported right away.
Cirrhosis and some cancers can fill the peritoneal space with liters of fluid. The nurse weighs the patient daily and measures abdominal girth at the same marked point in the same position, and raises the head of the bed if the fluid pushes on the diaphragm and makes breathing hard. Before a paracentesis the patient empties the bladder, and afterward the nurse watches for low blood pressure as fluid shifts.
Physiological AdaptationSafety and Infection ControlReduction of Risk Potential
Abdomen and pelvisHigh yield
Placenta and umbilical cord
The placenta is a flat organ attached to the inner wall of the uterus that exchanges oxygen, nutrients, and wastes between the mother's blood and the fetus's blood, and the umbilical cord carries that blood to and from the baby through two arteries and one vein.
Why the exam cares
Bleeding from a low-lying or separating placenta, or a cord that slips down ahead of the baby, puts two lives at risk fast, and the nurse must tell these emergencies apart by their signs and act at once. After birth the cord becomes a newborn check: count three vessels, then teach care of the stump.
- The placenta normally attaches in the upper part of the uterus, away from the cervix; it cannot be felt from outside
- Before birth, a uterus that feels board-hard and tender between contractions is a warning sign of blood trapped behind a separating placenta
- The cord enters the baby at the umbilicus; after clamping and cutting, the stump dries and usually falls off in about 1 to 2 weeks
- A prolapsed cord may be seen at the vaginal opening or felt ahead of the presenting part on a sterile vaginal exam
Painless, bright red bleeding late in pregnancy points to placenta previa, where the placenta lies over or near the cervix; the nurse does not do a vaginal exam or place anything in the vagina, because it can tear the placenta and cause hemorrhage. Painful bleeding with a rigid, tender uterus points to abruption; blood can hide behind the placenta, so the nurse watches maternal vital signs and the fetal heart rate for shock even when little blood shows.
If the cord is seen or felt ahead of the presenting part, the nurse calls for help, uses a sterile gloved hand to lift the presenting part off the cord, and holds it there until birth. The mother is placed in knee-chest or Trendelenburg so gravity eases pressure on the cord. The nurse never pushes the cord back in, because handling it can make the vessels spasm and cut off the baby's oxygen.
After birth the nurse inspects the cut cord and counts two arteries and one vein. A cord with only two vessels is reported, because a single artery is linked with kidney and heart defects and the newborn needs further evaluation.
The nurse teaches parents to keep the stump clean and dry, fold the diaper below it, give sponge baths until it falls off, and never pull it. Redness, swelling, or tenderness around the stump, a foul smell, or yellow drainage suggests infection and is reported. A fever of 100.4 F (38 C) or higher, poor feeding, or unusual sleepiness needs a call to the provider right away.
Health Promotion and MaintenanceReduction of Risk PotentialPhysiological Adaptation
Abdomen and pelvisHigh yield
Prostate
A walnut-sized male gland that sits just below the bladder and wraps around the first part of the urethra, with the rectum directly behind it.
Why the exam cares
The urethra runs straight through the prostate, so an enlarged gland is the usual reason an older man strains, dribbles, and cannot empty his bladder. NCLEX questions build on what follows: getting a catheter past the gland, keeping the catheter draining and the sodium safe after a TURP, and preventing falls from the blood pressure drop caused by alpha blockers.
- Directly under the bladder neck. The urethra passes through the middle of the gland, so anything that swells the gland narrows the outflow.
- Its back surface lies against the front wall of the rectum. That is why a gloved finger a short way inside the anus can feel it.
- It cannot be felt from the abdomen. In a man who cannot void, the firm, rounded mass above the pubic bone that is dull to percussion is the full bladder, not the prostate.
- It sits deep in the pelvis behind the pubic bone. BPH tissue is usually removed through the urethra (TURP), so there is no incision. Cancer surgery removes the whole gland through a lower abdominal incision, robotic ports, or the perineum.
If a straight catheter meets resistance in a man with BPH, the nurse stops and does not push. The nurse then gets a coude-tip catheter per provider order or facility policy and inserts it with the curved tip pointing up, so it rides over the bulging gland. Forcing a catheter can tear the urethra, create a false passage, and cause bleeding.
The nurse adjusts the three-way catheter irrigation to keep the drainage light pink without clots, and subtracts the irrigant from total output to get true urine output. If drainage stops, the nurse stops the inflow, checks the tubing, irrigates only as ordered, and calls the provider, because a blocked catheter lets the bladder swell against the raw, bleeding prostate bed. Bright red drainage or large clots are reported at once, and so are new confusion, nausea, a slow pulse, or rising blood pressure, which can mean fluid absorbed during surgery has dropped the sodium.
Terazosin and doxazosin relax the prostate and bladder neck but also relax blood vessels, so the nurse gives the first dose at bedtime, checks orthostatic blood pressure, and teaches the patient to rise slowly to prevent falls. Tamsulosin is more prostate-selective and is taken about 30 minutes after the same meal each day, but the patient still needs the same fall precautions. Finasteride and dutasteride shrink the gland over months instead, do not lower blood pressure, and cut the PSA roughly in half, and a woman who is or may be pregnant must not handle crushed or broken tablets.
The nurse draws the PSA before a rectal exam or catheterization, because handling the gland can raise the level. Recent ejaculation, prostatitis, and BPH can also raise it, so the nurse teaches that a high PSA is a screening result that needs follow-up, not a cancer diagnosis. During the rectal exam, the provider feels the back of the gland through the rectal wall. A normal gland feels smooth and rubbery, while a hard or fixed nodule is abnormal and needs follow-up.
Reduction of Risk PotentialPharmacological and Parenteral Therapies
Abdomen and pelvis
Small intestine
The coiled tube of duodenum, jejunum, and ileum that fills the center of the abdomen between the stomach and the colon, where nearly all nutrients and most water are absorbed.
Why the exam cares
An ileostomy sends liquid stool out before the colon can pull water back, so the patient loses fluid, sodium, and potassium all day; the nurse protects the skin, tracks output, and watches for dehydration. After abdominal surgery or opioids, the nurse must also recognize a quiet, swollen belly as ileus and act on it.
- The duodenum curves in a C-shape around the head of the pancreas in the upper abdomen; the jejunum and ileum coil through the middle of the belly around and below the umbilicus.
- The ileum ends at the ileocecal valve in the right lower quadrant, where it empties into the cecum of the large intestine.
- An ileostomy stoma is usually placed in the right lower abdomen; a colostomy is more often on the left.
After abdominal surgery or with opioids, the bowel can stop moving: hypoactive or absent bowel sounds, a distended belly, no flatus, nausea, and vomiting. The nurse keeps the patient NPO, expects an NG tube to suction as ordered to decompress the stomach, and gets the patient walking early because movement helps peristalsis return. Pain that turns severe or localized, or high-pitched sounds with cramping, can mean a mechanical obstruction and is reported.
Ileostomy output is liquid, constant, and full of digestive enzymes that break down skin, so the barrier opening is cut only about 1/16 to 1/8 inch larger than the stoma and the pouch is emptied when about one-third full. An ileostomy is never irrigated. A healthy stoma is pink or red and moist; a dusky, purple, or black stoma means its blood supply is failing and is reported at once.
Output may be scant for the first day or two, then turns liquid and stays highest over the first few weeks, thickening and falling over weeks to months as the bowel adapts. The nurse measures it, encourages fluids that include electrolytes, and watches for thirst, low urine output, dizziness, and low sodium and potassium. Enteric-coated and extended-release tablets can pass through before they dissolve, so the nurse checks with the prescriber or pharmacist about another form.
Vitamin B12, bound to intrinsic factor, is absorbed in the terminal ileum, so a patient who has lost much of that segment is at risk for B12 deficiency and often needs lifelong replacement. Iron is absorbed mainly in the duodenum, and fat and fat-soluble vitamins in the jejunum and ileum, so the nurse monitors for anemia, fatty stools, and weight loss after small-bowel loss.
Basic Care and ComfortReduction of Risk PotentialPhysiological Adaptation
Abdomen and pelvisHigh yield
Spleen
A soft, fist-sized organ high in the left upper abdomen, behind the stomach and under the lower left ribs, that filters old red blood cells and helps fight infection.
Why the exam cares
A blow to the left side can tear this blood-filled organ and cause hypovolemic shock, sometimes hours or days after the injury, so the nurse reads a rising pulse and falling blood pressure as bleeding. A patient without a working spleen cannot clear encapsulated bacteria, so the nurse treats any fever in that patient as an emergency.
- Left upper quadrant, up under the left rib cage, roughly behind ribs 9 through 11.
- Sits behind and to the left of the stomach, above the left kidney, against the underside of the diaphragm.
- A normal spleen is not felt. If the nurse can feel its edge below the left rib margin as the patient breathes in, it is enlarged.
- Palpation is gentle only. If the spleen is known to be enlarged or injured, the nurse does not press on it.
After a left-sided blow, fall, or seat-belt injury, the nurse watches for left upper quadrant pain and left shoulder pain (Kehr's sign), which comes from blood irritating the diaphragm. A rising heart rate, falling blood pressure, and pale, cool skin mean hypovolemic shock, so the nurse places two large-bore IVs, gives fluids or blood as ordered, and does not press deeply on the abdomen. Because bleeding can show up late, a patient sent home after left-sided trauma is taught to return at once for new belly or left shoulder pain, dizziness, or fainting.
In a young child with sickle cell disease, sudden pallor, weakness, a quickly growing left upper abdomen, and falling blood pressure mean blood is pooling in the spleen. The nurse treats this as shock, gets help, and prepares for a blood transfusion. Parents are taught how to feel their child's spleen and to come in right away if it gets bigger.
Without a spleen, infection from encapsulated bacteria such as pneumococcus, meningococcus, and Hib can turn into sepsis within hours. The nurse teaches that any fever means going to the emergency department now, not waiting it out at home, and reports a fever in this patient right away. The nurse also confirms pneumococcal, meningococcal, and Hib vaccines are given (ideally before an elective splenectomy) and teaches the patient to wear a medical alert ID and take any emergency antibiotic exactly as prescribed.
Mono can swell the spleen and make it easy to tear. The nurse teaches no contact sports or heavy lifting for at least about three to four weeks and until the provider gives clearance. During assessment the nurse avoids deep palpation of the left upper quadrant.
Physiological AdaptationReduction of Risk PotentialHealth Promotion and Maintenance
Abdomen and pelvisHigh yield
Stomach
A J-shaped muscular pouch in the left upper abdomen, just under the diaphragm, that takes food from the esophagus and empties it through the pylorus into the small intestine.
Why the exam cares
The stomach is where the feeding tube ends, so every NG placement check, residual check, and PEG-site question is really a question about this organ. It is also the site of the ulcer that perforates, the tight pylorus that makes a 3-week-old vomit across the room, and the surgery that leaves a patient with dumping syndrome.
- Left upper quadrant and the epigastric region just below the xiphoid process; most of it hides behind the lower left ribs.
- Sits under the left dome of the diaphragm, with the spleen to its left and the liver over its right edge.
- NG tube length is measured from the nose tip to the earlobe to the xiphoid process (NEX) so the tip lands in the stomach, not the esophagus.
- A PEG tube exits the abdominal wall in the left upper quadrant; the stoma is what the nurse inspects and cleans.
Before the first feeding the nurse confirms tube position with an X-ray; after that, aspirate pH of about 5 or lower supports a gastric tip, while a higher pH suggests the intestine or the lung. The nurse checks gastric residual per protocol, keeps the head of the bed at 30 to 45 degrees during and after feeds, and flushes with water before and after every feeding and medication.
Sudden severe epigastric pain with a rigid, board-like abdomen, absent bowel sounds, and a patient who lies still means the stomach has leaked into the peritoneum. The nurse makes the patient NPO, notifies the provider at once, starts IV access, and prepares for surgery, because peritonitis and sepsis follow within hours.
A 3 to 6 week old with projectile, non-bilious vomiting right after feeds, a firm olive-shaped mass in the epigastrium, and a hungry cry afterward has a thickened pylorus. Repeated loss of stomach acid causes dehydration and metabolic alkalosis with low potassium and chloride, so the nurse expects IV fluid and electrolyte correction before the pyloromyotomy.
Without a stomach to hold food back, a meal rushes into the small intestine and pulls fluid with it, causing cramping, sweating, dizziness, and diarrhea soon after eating. The nurse teaches small dry meals high in protein and low in simple sugars, no fluids with meals (drink 30 to 60 minutes before or after), and lying down for 20 to 30 minutes after eating to slow emptying.
Reduction of Risk PotentialPhysiological Adaptation
Abdomen and pelvis
Ureters
Two narrow muscular tubes, each about 10 to 12 inches long, that carry urine from the kidneys down the back wall of the abdomen to the bladder.
Why the exam cares
A kidney stone that lodges in a ureter causes renal colic, and the nurse must treat the pain, strain the urine, and catch the fever or falling output that turns a stone into an emergency. When the bladder is removed, the ureters drain through an ileal conduit, and the nurse must judge that stoma and its output.
- Each ureter runs down behind the peritoneum from the kidney, over the front of the psoas muscle, crosses the brim of the bony pelvis, and enters the back of the bladder at an angle.
- Stones tend to lodge at three narrow points: where the ureter leaves the kidney, where it crosses the pelvic brim, and where it enters the bladder.
- Colic pain follows the tube: from the flank, around to the lower abdomen, then into the groin and genitals.
Sudden, severe flank pain comes in waves and spreads toward the groin, often with nausea, vomiting, and blood in the urine, and the patient usually cannot lie still. The nurse gives the ordered analgesic promptly, encourages fluids unless they are restricted, and tracks intake and output. One blocked ureter usually leaves total output near normal because the other kidney makes up for it, so output that drops sharply or stops can mean both sides or an only working kidney are blocked, but it can also come from fluid lost to vomiting, early sepsis, or kidney injury; the nurse reports it at once rather than waiting to learn the cause.
Infected urine trapped behind a blocking stone can spread into the blood quickly, and antibiotics alone will not clear it until the provider drains the kidney with a ureteral stent or a nephrostomy tube. Fever, chills, a rising heart rate, or a falling blood pressure in a patient with a stone is reported immediately. The nurse draws the ordered blood and urine cultures before the first antibiotic dose, starts the ordered IV fluids and antibiotics, prepares the patient for the drainage procedure, and watches blood pressure, mental status, and urine output for signs of septic shock.
Every void goes through a strainer so the stone can be caught and sent for analysis, because the stone's type guides the diet and medicines that prevent the next one. The nurse teaches the patient to keep straining at home and bring in any stone, since a stone may pass after discharge.
After the bladder is removed, the ureters are joined to a short piece of small intestine that opens on the abdomen as a stoma and drains urine all the time, so mucus shreds in the urine are expected. The nurse checks that the stoma is pink or red and moist and reports a dusky, purple, or black stoma at once because its blood supply is failing; a conduit that stops draining or whose output drops sharply is also reported at once, because blocked urine backs up toward the kidneys. The nurse keeps the pouch emptied and the skin around the stoma dry to prevent breakdown, and teaches that foul-smelling urine with fever or flank pain signals infection.
Basic Care and ComfortReduction of Risk PotentialPhysiological Adaptation
Abdomen and pelvisHigh yield
Urethra
The tube that carries urine from the bladder out of the body: short and straight in women, long and curved in men, where it runs through the prostate and the penis.
Why the exam cares
The urethra's length sets how far the nurse advances a urinary catheter and how easily bacteria reach the bladder. Correct insertion depth, waiting to inflate the balloon, and daily catheter care prevent urethral injury and catheter-associated infection.
- In women the opening sits between the clitoris and the vaginal opening, and the urethra runs only about 1.5 inches to the bladder.
- In men it runs about 8 inches: through the prostate just below the bladder, then a bend near the base of the penis, then the length of the penis.
- Holding the penis upright at a 90-degree angle to the body straightens that bend so the catheter passes more easily.
- If a catheter slips into the vagina, the nurse leaves it there as a marker and inserts a new sterile catheter just above it.
Using sterile technique, the nurse advances the lubricated catheter about 2 to 3 inches in a woman, or about 7 to 9 inches in a man with the penis held at 90 degrees, until urine flows, then advances it further before inflating the balloon: about 1 to 2 inches more in a woman, to the Y-junction in a man. A balloon inflated inside the urethra tears it, causing bleeding, pain, and later scarring. If the catheter meets resistance, the nurse stops, does not force it, and notifies the provider.
The nurse returns the foreskin over the glans at the end of every catheter insertion and every round of catheter care. Left retracted, it tightens behind the glans, the glans swells, and blood flow is cut off. If the foreskin cannot be brought forward over a swollen glans, the nurse notifies the provider at once, because the tissue can die without prompt treatment.
Each day a catheter stays in raises the risk of infection, so the nurse asks daily whether it is still needed and removes it as soon as the order or protocol allows. While it is in, the nurse keeps the bag below bladder level and off the floor, keeps the tubing free of dependent loops, secures the catheter, keeps the system closed, collects samples from the sampling port rather than the bag, and cleans the perineum and the catheter at the meatus daily.
The short female urethra sits close to the anus, so bacteria reach the bladder easily; the nurse teaches wiping front to back, voiding after intercourse, drinking enough fluid, and not holding urine. Burning, frequency, and urgency are typical in younger adults, but in an older adult new confusion may be the only sign. The nurse reports that change promptly rather than waiting for fever, because an untreated UTI can progress to sepsis.
Safety and Infection ControlBasic Care and ComfortReduction of Risk Potential
Abdomen and pelvisHigh yield
Uterus
A pear-shaped muscular organ in the pelvis behind the bladder that grows from the size of a fist to fill the abdomen in pregnancy, then shrinks back after birth.
Why the exam cares
The top of the uterus (the fundus) is a bedside ruler for fetal growth before birth and the nurse's first defense against hemorrhage after it. The NCLEX asks where it should be, what to do when it is soft, and how to read a shift to the right.
- Sits low in the pelvis behind the pubic bone and in front of the rectum, above the bladder.
- In pregnancy the fundus reaches the pubic symphysis at about 12 weeks and the umbilicus at about 20 weeks; after that the height in centimeters roughly equals the weeks.
- Right after birth the fundus is at the umbilicus, firm and midline, and drops about one finger width a day until it is back in the pelvis in about two weeks.
- A fundus pushed up and to the right means a full bladder beneath it.
With the patient supine and bladder empty, the nurse measures from the top of the pubic bone to the top of the fundus. From about 20 to 36 weeks the centimeters should match the weeks within a couple of centimeters; a measurement that lags or jumps prompts an ultrasound for growth, fluid, or dates.
The nurse supports the bottom of the uterus with one hand above the pubic bone and palpates the fundus with the other, noting firmness, height, and position. A boggy fundus is massaged until firm; a fundus above the umbilicus or shifted to the right means a full bladder, so the nurse has the patient void or catheterizes and rechecks. Lochia and the perineum are checked at the same time.
A uterus that will not stay contracted (atony) is the leading cause. A pad soaked in about 15 minutes, a steady trickle, large clots, or a rising pulse with falling blood pressure sends the nurse to massage the fundus, empty the bladder, give oxytocin as ordered, and call for help, because a postpartum patient can lose a liter before her pressure moves.
Health Promotion and MaintenancePhysiological Adaptation
