A nurse is admitting a client who is at 39 weeks of gestation and in active labor.
The client reports being positive for group B streptococcus (GBS) when screened at 36 weeks of gestation. Which of the following actions should the nurse expect to take?

Choice A rationale

A perineal hematoma is a collection of blood in the connective tissue beneath the skin, often caused by trauma during childbirth. The reported findings of increasing perineal pain, pressure, purplish discoloration, and swelling are classic signs. The purplish hue indicates extravasated blood, and the swelling reflects the accumulation of fluid, which can exert significant pressure on surrounding tissues, leading to severe discomfort and a palpable mass.

Choice B rationale

Retained placental fragments typically manifest as persistent or excessive postpartum bleeding, often bright red, and can lead to uterine subinvolution and infection. While pain might be present due to uterine contractions, it would not typically present as a localized, purplish, swollen area on the perineum. This finding is not consistent with the pathophysiology of retained placental fragments, which primarily affects the uterus.

Choice C rationale

A laceration is a tear in the soft tissues of the perineum or vagina, resulting in bright red bleeding, pain, and sometimes a visible opening. While pain is present, a laceration would not typically present with a 4 cm purplish discoloration and significant swelling without active, bright red bleeding from the tear site itself. The described findings are more indicative of internal bleeding and tissue accumulation rather than an open wound.

Choice D rationale

Ecchymosis is a bruise, characterized by superficial extravasation of blood into the skin or mucous membranes, resulting in a purplish discoloration. While the purplish discoloration is consistent, ecchymosis alone typically does not involve the significant palpable swelling and increasing pressure described. The extent of swelling and pressure points to a deeper collection of blood, distinguishing it from simple superficial bruising.

Choice A rationale

Tinnitus, a ringing sensation in the ears, is not a commonly reported adverse effect of nifedipine. Nifedipine is a calcium channel blocker primarily used to relax smooth muscle, including in the uterus and blood vessels. Its common side effects are typically related to its vasodilatory action rather than ototoxicity.

Choice B rationale

Irregular heartbeat, specifically palpitations or tachycardia, is an important adverse effect of nifedipine that warrants notifying the provider. Nifedipine can cause reflex tachycardia due to its vasodilatory effects, which can be significant in some individuals. Monitoring for and reporting changes in cardiac rhythm is crucial to ensure patient safety and appropriate management.

Choice C rationale

Hair loss, or alopecia, is not a recognized or common adverse effect associated with nifedipine therapy. The mechanism of action of nifedipine does not typically interfere with hair follicle function or growth cycles. Adverse drug reactions associated with nifedipine are generally cardiovascular or gastrointestinal in nature.

Choice D rationale

Increased salivation is not a typical or expected adverse effect of nifedipine. Common side effects of nifedipine often include dizziness, headache, flushing, peripheral edema, and nausea, primarily due to its vasodilatory properties. Changes in salivary gland function are not commonly implicated with nifedipine use.