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 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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A rationale

Cooling the newborn's heel causes vasoconstriction, which reduces blood flow to the area. This would make it more difficult to obtain an adequate blood sample and could lead to repeated punctures, increasing the risk of discomfort and tissue damage for the newborn. Optimal blood flow is crucial for a successful heel stick.

Choice B rationale

Puncturing the center of the newborn's heel risks damaging the calcaneus bone, which can lead to osteomyelitis, an infection of the bone. The proper technique involves puncturing the lateral aspects of the heel to avoid bone injury and ensure patient safety.

Choice C rationale

Cleansing the puncture site with an alcohol gauze pad prior to the procedure is essential for asepsis. Alcohol acts as an antiseptic by denaturing proteins and dissolving lipids in bacterial cell membranes, effectively reducing the microbial load on the skin surface and minimizing the risk of introducing pathogens into the bloodstream during the puncture.

Choice D rationale

Administering vitamin K is typically done shortly after birth to prevent hemorrhagic disease of the newborn, as newborns have immature livers and insufficient gut flora for vitamin K synthesis. It is not routinely administered 30 minutes prior to every blood draw and is unrelated to the immediate procedure of obtaining a heel stick sample.

A. Shrill cry. B. Weak peripheral pulses. C. Yellowish skin. D. Hypotonia.

Correct Answer is A

Explanation

Choice A rationale

A shrill or high-pitched cry in a newborn can be a symptom of neurological irritability, which is often associated with hypoglycemia. Hypoglycemia in newborns can lead to central nervous system dysfunction due to insufficient glucose supply to the brain, manifesting as altered cry patterns.

Choice B rationale

Weak peripheral pulses can indicate poor cardiac output or peripheral vasoconstriction, which might be associated with conditions like congenital heart defects or hypovolemia. While significant hypoglycemia can impact cardiovascular function, weak pulses are not the primary or most specific indicator.

Choice C rationale

Yellowish skin, or jaundice, is caused by elevated bilirubin levels in the blood, often due to physiological immaturity of the liver or increased red blood cell breakdown. While jaundice can be a symptom of various newborn issues, it is not a direct or common sign of hypoglycemia.

Choice D rationale

Hypotonia, or decreased muscle tone, can be a symptom of various neurological issues, including severe hypoglycemia, but also other conditions like birth trauma, sepsis, or genetic disorders. While it can be present with hypoglycemia, a shrill cry is a more specific and earlier indicator.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning to obtain a blood specimen from a newborn via a heel stick. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is assessing a newborn. Which of the following findings indicates a need to check the newborn's blood glucose level for hypoglycemia?

Correct Answer is A

Explanation

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 completing a health history and assessment for a client who reports they are pregnant. Which of the following findings is a presumptive sign of pregnancy?

A nurse is caring for a 2-day-old newborn who has a bilirubin level of 14 mg/dL (1 to 12 mg/dL) and is to begin phototherapy. Which of the following actions should the nurse take?

A nurse is collecting a blood phenylketonuria (PKU) test for a newborn prior to discharge. The newborn's guardian asks the nurse what a positive PKU test would mean. Which of the following statements should the nurse make?

A nurse is assessing a client who is 6 hours 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 reviewing the laboratory results for a client who is at 29 weeks of gestation and has a history of anemia. Which of the following results should the nurse identify and report as an indication of a prenatal complication?

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 assessing a client who is at 8 weeks of gestation and has hyperemesis gravidarum. Which of the following are findings of this condition? (Select all that apply.)