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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is ["A","C","E"]

Explanation

Choice A rationale

Prior to IUD insertion, screening for sexually transmitted infections (STIs) is crucial to prevent the introduction of pathogens into the upper reproductive tract. An untreated STI, particularly chlamydia or gonorrhea, can lead to pelvic inflammatory disease (PID) when an IUD is placed, as the device might facilitate the ascent of bacteria.

Choice B rationale

The duration of effectiveness for intrauterine devices varies depending on the type. Hormonal IUDs typically last for 3 to 8 years, while copper IUDs can remain effective for up to 10 years. Therefore, the statement that the device must be replaced every 2 years is incorrect and misleading for most available IUDs.

Choice C rationale

Irregular spotting and changes in menstrual bleeding patterns are common side effects during the initial months following IUD placement, particularly with hormonal IUDs. This is due to the local endometrial effects of progesterone release or the inflammatory reaction induced by copper, as the uterus adapts to the foreign body.

Choice D rationale

There is no medical contraindication to using tampons with an IUD. The IUD resides in the uterus, while tampons are inserted into the vaginal canal. There is no physical interaction or risk of dislodgement of the IUD by tampon use. Clients can continue their preferred menstrual hygiene products.

Choice E rationale

Informed consent is a fundamental ethical and legal requirement before any medical procedure, including IUD insertion. The client must be provided with comprehensive information regarding the procedure, including its benefits, risks, alternatives, and potential side effects, to make an autonomous and voluntary decision.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

The nurse should identify that weeks of gestation and contraction pattern are findings that require follow-up.

Rationale for correct answers:
Weeks of gestation at 32 weeks indicate a preterm pregnancy (<37 weeks), making any contractions concerning for possible preterm labor. The contraction pattern of increasing frequency (from every 5 minutes to every 3 minutes), longer duration (30 to 60 seconds), and moderate intensity signifies active uterine activity that can precipitate cervical changes and preterm birth risk. These two parameters warrant close monitoring and intervention to prevent premature delivery.

Rationale for incorrect answers (Response 1 options):
Blood pressure is within normal limits (128/83 and 117/80 mm Hg), so hypertensive disorders like preeclampsia are not indicated here. Pain score remains low (2/10), which is mild and not a primary indicator for urgent intervention. Parity (G1P0) does not influence immediate risk assessment for this clinical presentation.

Rationale for incorrect answers (Response 2 options):
Fetal heart rate remains normal at 140/min with no decelerations, indicating fetal well-being at this time. Nitrazine test is negative, showing intact membranes, which reduces the risk of premature rupture of membranes. Temperature is normal at 37°C, ruling out infection as a cause of contractions. Therefore, these findings do not require urgent follow-up in this scenario.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing client teaching regarding an intrauterine device (IUD). Which of the following statements should the nurse include in the teaching?

Correct Answer is ["A","C","E"]

Explanation

A nurse is caring for a female client who is gravida 1 para 0 at 32 weeks of gestation in the antepartum unit. Complete the following sentence by using the list of options. The nurse should identify that ____________ and ___________ are findings that require follow-up.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

A nurse is preparing to administer methotrexate to a client who is experiencing an ectopic pregnancy. 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 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 is at 33 weeks of gestation. Which of the following findings should the nurse report to the provider?

A nurse is caring for a newborn immediately following birth. The newborn has meconium-stained amniotic fluid. Which of the following actions should the nurse take first?

A nurse is caring for a client who is at 28 weeks of gestation and has received two doses of terbutaline subcutaneously. Which of the following adverse effects is the priority for the nurse to report to the provider?

A nurse is reviewing the results of a nonstress test for a client who is at 37 weeks of gestation. Which of the following findings indicates a reactive nonstress test?

A nurse is caring for a female client who is gravida 1 para 0 at 32 weeks of gestation in the antepartum unit. The nurse should anticipate the provider will prescribe ________ and _________.