A nurse is caring for a client who had a vacuum-assisted delivery due to prolonged labor and is at risk for developing a hematoma in the perineal area.
Which of the following manifestations should alert the nurse to this complication?
Severe perineal pain
Bright red vaginal bleeding
Decreased hemoglobin level
Elevated white blood cell count
The Correct Answer is A
Severe perineal pain is a manifestation of a hematoma in the perineal area, which can result from vacuum-assisted delivery. A hematoma is a collection of blood under the skin or in the tissues that can cause pressure and pain.
Normal ranges for hemoglobin are 12 to 16 g/dL for women and 14 to 18 g/dL for men. Normal ranges for white blood cell count are 4,000 to 11,000 cells per microliter of blood.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A"]
Explanation
A boggy uterus is a sign of uterine atony, which is the failure of the uterus to contract sufficiently after childbirth.
This can lead to excessive bleeding and postpartum hemorrhage.
A firm fundus at the umbilicus is a normal finding after delivery and indicates that the uterus is contracting well.
Excessive lochia rubra is also a sign of uterine atony and postpartum hemorrhage.Lochia rubra is the vaginal discharge composed of blood, mucus, and tissue from the placenta and the uterus lining that occurs after childbirth.
It is normal for the first 3 to 4 days, but it should gradually decrease in amount and change in color.
Clots larger than a quarter are abnormal and indicate excessive bleeding.
A pulse rate of 110/min is a sign of tachycardia, which can be caused by blood loss, infection, or pain.
A normal pulse rate for an adult is between 60 and 100 beats per minute.
Correct Answer is A
Explanation
Crowning is when the fetal head is visible at the vaginal opening and does not slip back in with each contraction.This indicates that the baby is ready to be born and the mother should stop pushing to avoid tearing or the need for an episiotomy.
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