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.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Uric acid levels in preeclampsia can be elevated due to decreased renal clearance and increased production, often exceeding the normal range of 2.7 to 7.3 mg/dL. A value of 7.5 mg/dL is slightly elevated, which is a common finding in preeclampsia and does not typically contraindicate the administration of labetalol, an antihypertensive medication. It reflects disease progression but does not pose an immediate risk regarding medication administration.
Choice B rationale
Labetalol is a beta-blocker that reduces heart rate and blood pressure. A heart rate of 54/min is below the normal adult resting heart rate range (typically 60-100 beats/min) and indicates bradycardia. Administering labetalol to a client with pre-existing bradycardia could further depress the heart rate, potentially leading to symptomatic bradycardia, decreased cardiac output, and inadequate tissue perfusion, thus requiring the nurse to withhold the medication.
Choice C rationale
A fetal heart rate (FHR) of 112/min is within the normal range for a fetus (typically 110-160 beats/min). While labetalol can rarely cause fetal bradycardia, a baseline FHR of 112/min does not contraindicate its administration. The primary concern with labetalol in preeclampsia is the maternal hemodynamic response, and this FHR value does not indicate an immediate fetal distress that would preclude the medication.
Choice D rationale
A BUN level of 23 mg/dL is slightly elevated above the normal range of 10 to 20 mg/dL, often seen in preeclampsia due to impaired renal function. While this indicates renal involvement, it does not contraindicate the administration of labetalol. Labetalol is primarily metabolized by the liver, and while caution is advised in renal impairment, this BUN level alone does not warrant withholding the medication.
Correct Answer is C
Explanation
Choice A rationale
Giving glucose water after feedings is not recommended for newborns undergoing phototherapy for hyperbilirubinemia. Glucose water provides no nutritional benefit, can lead to decreased breast milk intake, and does not aid in the excretion of bilirubin, which is primarily excreted through conjugated bile in stool.
Choice B rationale
Instructing the client to avoid breastfeeding during treatment for hyperbilirubinemia is incorrect. Breastfeeding should be continued and encouraged, as adequate hydration and caloric intake are crucial for promoting bowel movements, which help in the excretion of bilirubin from the body. Interruption of breastfeeding can also negatively impact milk supply.
Choice C rationale
Monitoring intake and output is critical for a newborn undergoing phototherapy. Phototherapy can increase insensible fluid losses through the skin, potentially leading to dehydration. Close monitoring of fluid intake (e.g., breastfeeding, formula) and urine/stool output ensures adequate hydration and helps assess the effectiveness of bilirubin excretion.
Choice D rationale
Applying lotions and ointments throughout phototherapy treatment is contraindicated. These products can absorb the light emitted by the phototherapy unit, leading to potential burns or uneven light distribution on the newborn's skin, thereby reducing the effectiveness of the treatment for hyperbilirubinemia.
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