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.

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

Explanation

The nurse should first monitor the client’s fundal tone followed by the client’s heart rate.

Rationale for correct answers
Fundal tone is the primary indicator of uterine contractility. A boggy fundus that does not firm with massage indicates uterine atony, the most common cause of postpartum hemorrhage (PPH). Effective uterine contraction compresses uterine blood vessels to reduce bleeding. Monitoring fundal tone allows early identification of hemorrhage risk. Heart rate is a sensitive early sign of hypovolemia; a rising heart rate (tachycardia above 100 beats/min) reflects compensatory response to blood loss before blood pressure drops. Normal adult heart rate ranges from 60 to 100 beats/min; an increase indicates circulatory stress.

Rationale for incorrect answers
Bruising to perineal area (A) is important but secondary; it does not directly assess bleeding severity or uterine status. Pain level (C) is subjective and can be influenced by many factors; it does not reliably indicate hemorrhage. Uterine height (D) measures fundal location but does not assess firmness or tone, which are critical for detecting atony. Temperature (B) changes are not immediate indicators of bleeding. Pain level (C) and uterine height (D) similarly lack specificity for hemorrhage assessment compared to fundal tone and heart rate.

Take home points

Fundal tone assessment is critical for early detection of uterine atony causing postpartum hemorrhage.
Tachycardia is an early physiological sign of hypovolemia and should be closely monitored.
Perineal bruising and pain are secondary findings and less specific to hemorrhage severity.
Uterine height and temperature changes do not reliably indicate acute hemorrhage status.

A. Repeat the CST in 20 minutes. B. Administer an intravenous fluid bolus. C. Prepare the client for cesarean birth. D. Allow the labor to progress naturally.

Correct Answer is D

Explanation

Choice A rationale

A negative contraction stress test (CST) indicates that the fetus tolerates uterine contractions well, with no evidence of late decelerations, implying adequate uteroplacental function. Repeating the test in 20 minutes is unnecessary as a negative result signifies fetal well-being and is a favorable outcome.

Choice B rationale

Administering an intravenous fluid bolus is often used in situations like non-reassuring fetal heart rate patterns or to improve uteroplacental perfusion, such as during a non-reactive non-stress test or before an oxytocin challenge. A negative CST indicates a healthy fetus, so a fluid bolus is not indicated.

Choice C rationale

Preparing for a cesarean birth is indicated when there is evidence of fetal distress or a high risk of adverse outcomes, such as with a positive CST (late decelerations present). A negative CST indicates a reassuring fetal status, making a cesarean birth unnecessary based solely on these test results.

Choice D rationale

A negative CST indicates a healthy fetus with good uteroplacental reserve, suggesting that the fetus will likely tolerate the stress of labor. Therefore, allowing the labor to progress naturally is the appropriate action, as there are no indications of fetal compromise.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a female client who is in the fourth stage of labor in the postpartum unit. Complete the following sentence by using the list of options. The nurse should first monitor the client’s ________ followed by the client’s __________.

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

Explanation

A nurse is performing a contraction stress test (CST) on a client who is at 40 weeks of gestation. The results of the test indicate a negative CST. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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