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

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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.

A. Perform frequent vaginal exams. B. Change perineal pads every 2 hours. C. Encourage oral fluid intake. D. Administer IV antibiotics as prescribed. E. Use sterile gloves when providing perineal care.

Correct Answer is ["B","C","D","E"]

Explanation

These actions can help reduce the risk of infection for the client who has prolonged labor.

• ChoiceBis correct because changing perineal pads every 2 hours can prevent bacterial growth and contamination of the genital tract.

• ChoiceCis correct because encouraging oral fluid intake can help maintain hydration and blood volume, which can improve uterine perfusion and prevent maternal and fetal acidosis.

• ChoiceDis correct because administering IV antibiotics as prescribed can prevent or treat maternal peripartum infections, which are among the leading causes of maternal mortality worldwide.

• ChoiceEis correct because using sterile gloves when providing perineal care can prevent introducing pathogens into the genital tract.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who had a prolonged labor and is at risk for uterine atony. Which of the following findings should indicate to the nurse that the client has this condition? Select all that apply.

Correct Answer is ["A"]

Explanation

A nurse is caring for a client who has prolonged labor and is at risk for infection. Which of the following actions should the nurse take to reduce this risk? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is reviewing the risk factors for uterine rupture with a group of nursing students. Which of the following risk factors should the nurse include? (Select all that apply.)

A nurse is reviewing the partograph of a client in labor. The nurse notes that the cervical dilation curve is above the alert line and below the action line. What does this indicate?

A gush of blood is noted with the rupture of membranes. On palpation, the uterus is soft (i.e., relaxed) and the patient is not reporting any pain. An FHR deceleration down to 90 bpm is noted. What does the nurse suspect has happened?

A nurse is caring for a client who is in active labor and experiencing shoulder dystocia. Which of the following actions should the nurse take? (Select all that apply.).

A nurse is caring for a client who has prolonged and obstructed labor and develops a vesicovaginal fistula. Which of the following interventions should the nurse include in the plan of care?

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?

A nurse is assessing a client who is in labor and notes that the fetal head is visible at the vaginal opening but does not advance with pushing. The nurse should identify this finding as which of the following?

A nurse is assessing a client who is in labor and has been pushing for 3 hours with no progress. The nurse should identify that this client is at risk for which of the following complications? (Select all that apply.).

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?