A nurse is assessing a client who had a prolonged labor and vacuum-assisted birth.
The nurse observes a large, tense, bluish bulge on the client’s perineum.
The client reports severe pain in the area.
What is the most likely diagnosis for this client?
Perineal hematoma
Vulvar varicosity
Rectocele
Episiotomy
The Correct Answer is A
Perineal hematoma. A perineal hematoma is a collection of blood in the soft tissues of the perineum that can result from trauma during delivery, such as vacuum-assisted birth. The client may present with a large, tense, bluish bulge on the perineum and severe pain in the area.
Choice B. Vulvar varicosity is wrong because it is a condition where the veins in the vulva become enlarged and swollen due to increased blood flow and pressure during pregnancy. It usually appears as bluish or purple veins on the vulva and may cause discomfort, itching, or heaviness in the area.
It is not related to vacuum-assisted birth or prolonged labor.
Choice C. Rectocele is wrong because it is a condition where the rectum bulges into the vagina due to weakening of the pelvic floor muscles and connective tissue.
It may cause symptoms such as difficulty with bowel movements, a feeling of pressure or fullness in the vagina, or sexual dysfunction.
It is not related to vacuum-assisted birth or prolonged labor.
Choice D. Episiotomy is wrong because it is a surgical incision made in the perineum to enlarge the vaginal opening during delivery.
It may be done to facilitate delivery, prevent severe tearing, or protect the baby’s head from trauma.
It is not a diagnosis but a procedure that may be performed during vacuum-assisted birth or normal vaginal delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Oxytocin is a hormone that causes the uterine muscles to contract and compress the blood vessels that connect the uterus to the placenta.This helps prevent excessive bleeding after delivery, especially in cases of uterine atony, which is the failure of the uterus to contract sufficiently.
Choice B is wrong because oxytocin does not have any direct effect on infection or wound healing.
Choice C is wrong because oxytocin does not enhance milk production, although it does facilitate milk ejection during breastfeeding.Choice D is wrong because oxytocin does not relieve pain or discomfort from uterine cramping, but rather causes it by stimulating contractions.
Correct Answer is ["A","B","C","E"]
Explanation
These are the instructions that the nurse should include in the teaching for a client who had a postpartum hemorrhage due to uterine atony.
• Choice A is correct because foul-smelling lochia or fever can indicate an infection of the uterus or other reproductive organs, which can worsen bleeding and cause complications.
• Choice B is correct because iron intake and supplements can help replenish the blood loss and prevent anemia.
• Choice C is correct because sexual intercourse can cause trauma to the healing tissues and increase the risk of infection and bleeding.The lochia usually stops within four to six weeks after delivery.
• Choice D is wrong because limiting fluid intake can cause dehydration and impair blood circulation and clotting.The client should drink plenty of fluids to stay hydrated and promote healing.
• Choice E is correct because pelvic floor exercises can help strengthen the muscles that support the uterus and bladder, and prevent prolapse and urinary incontinence.
Uterine atony is a condition where the uterus does not contract enough after delivery, which can lead to excessive bleeding or postpartum hemorrhage.It is the most common cause of postpartum hemorrhage, accounting for up to 80% of cases.It can be caused by several factors, such as multiple pregnancy, large baby, prolonged or rapid labor, obesity, uterine fibroids, or medications that affect uterine contractions.It requires immediate medical treatment to stop the bleeding and prevent shock and organ failure.
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