A nurse is caring for a client who had a vaginal delivery 2 hr ago and is reporting increasing perineal pain and pressure.The nurse examines the client's perineum and sees a 4 cm (1.6 in) area of purplish discoloration with swelling.
The nurse should interpret these findings as which of the following?

A hematoma.

Retained placental fragments.

A laceration.

Ecchymosis.

Answer and Explanation

The Correct Answer is A

Choice A rationale

A hematoma presents as a localized collection of blood outside the blood vessels, causing a purplish discoloration and swelling, often resulting from trauma during delivery.

Choice B rationale

Retained placental fragments may cause postpartum hemorrhage and infection but would not present as a localized purplish swelling on the perineum.

Choice C rationale

A laceration would involve a tear in the tissue, causing bleeding and pain, but not necessarily a purplish discoloration with localized swelling unless associated with a hematoma.

Choice D rationale

Ecchymosis refers to bruising but is typically a more diffuse discoloration rather than a localized swelling and purplish area as seen with a hematoma.

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Correct Answer is D

Explanation

Choice A rationale

Only one dose of rubella immunization is necessary post-delivery, no need for a second dose in 2 weeks.

Choice B rationale

Prevention of pregnancy is recommended for at least 1 month (not 4 months) after receiving the rubella vaccine to avoid possible teratogenic effects.

Choice C rationale

An additional rubella immunization is not recommended during pregnancy as the live vaccine is contraindicated during gestation.

Choice D rationale

Rubella vaccine is safe for breastfeeding mothers, as it does not affect the safety of breast milk.

A. A newborn who has a respiratory rate of 34/min. B. A newborn who has acrocyanosis. C. A newborn who has caput succedaneum. D. A newborn who has an axillary temperature of 36°C (96.8°F).

Correct Answer is D

Explanation

Choice A rationale

A respiratory rate of 34/min is within the normal range for a newborn, which is typically between 30 to 60 breaths per minute. This does not indicate immediate distress.

Choice B rationale

Acrocyanosis, or bluish discoloration of the hands and feet, is common in newborns and usually resolves within the first few days of life. It is not a sign of critical illness.

Choice C rationale

Caput succedaneum, a swelling of the soft tissues of the newborn's scalp, is a common and benign condition that resolves on its own within a few days. It does not require immediate medical attention.

Choice D rationale

An axillary temperature of 36°C (96.8°F) is considered low and may indicate hypothermia in a newborn. Hypothermia can lead to serious complications, so this newborn requires immediate assessment and intervention to stabilize their body temperature.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to a postpartum client who had no immunity to rubella and received the rubella immunization.Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is receiving a report on four newborns born in the past 12 hr. Which of the following newborns should the nurse assess first?

Correct Answer is D

Explanation

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?

A nurse is monitoring a client who is in the active phase of labor and has an electronic fetal monitor.Which of the following findings should the nurse expect?

A nurse is assessing a client who has placenta previa and is receiving fetal monitoring.Which of the following clinical findings should the nurse expect?

A nurse is assessing a client who is 6 hr postpartum, tachycardic, and has cool skin.The client reports that they have been bleeding excessively.Which of the following actions should the nurse take?

A nurse is teaching a class to clients who are pregnant.Which of the following topics should the nurse include in the discussion about cesarean birth? (Select all that apply.)

A nurse is admitting a client who is at 9 weeks of gestation and in active labor when screened at 6 weeks of gestation.Which of the following actions should the nurse take?

A nurse is caring for a client who is 3 days postpartum in the postpartum unit. Exhibits A nurse is caring for a client who is 3 days postpartum. Which of the following actions should the nurse take?

A nurse is developing a plan of care for a client who is in the latent phase of labor.Which of the following interventions should the nurse include in the plan to manage the client's pain?