A nurse is reinforcing teaching with a client who is in labor about an episiotomy. Which of the following information should the nurse include?
An episiotomy is an incision that is made by the provider to facilitate delivery of the fetus.
An episiotomy is a perineal tear that is created while pushing during labor.
A mediolateral episiotomy is easier to repair than a median episiotomy
A fourth-degree episiotomy is always needed.
The Correct Answer is A
A. An episiotomy is an incision that is made by the provider to facilitate delivery of the fetus. An episiotomy is a surgical incision made in the perineum to enlarge the vaginal opening for delivery and reduce the risk of severe perineal tearing.
B. An episiotomy is a perineal tear that is created while pushing during labor. An episiotomy is an intentional incision, while a perineal tear is an unplanned, spontaneous laceration that occurs during pushing.
C. A mediolateral episiotomy is easier to repair than a median episiotomy. A median episiotomy is typically easier to repair and has less associated pain than a mediolateral incision, which is made at an angle.
D. A fourth-degree episiotomy is always needed. A fourth-degree episiotomy, which extends through the rectal mucosa, is rarely performed and is not always needed. Most episiotomies are less severe.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Nothing—this is a normal finding. Fetal heart rate accelerations are reassuring and indicate good fetal oxygenation and well-being. No intervention is needed.
B. Place patient on her left side. Changing position is an intervention for decelerations or abnormal fetal heart rate patterns, not for accelerations.
C. Give oxygen: Oxygen is administered in cases of fetal distress, such as prolonged decelerations or bradycardia, but not for normal accelerations.
D. Call provider. Accelerations are a positive sign, and there is no need to call the provider for this normal finding.
Correct Answer is B
Explanation
A. Check the fluid with Nitrazine paper. While this test can confirm if the membranes have ruptured, assessing the fetal heart rate (FHR) is more critical to ensure that there is no fetal distress due to umbilical cord prolapse.
B. Assess the FHR. After suspected rupture of membranes, the priority is to assess the fetal heart rate to check for potential complications like umbilical cord prolapse, which can cause fetal distress.
C. Note the color of the fluid. Assessing the color of the fluid is important, especially if meconium is present, but it is secondary to ensuring fetal well-being by assessing the FHR first.
D. Notify the health care provider. The provider should be notified, but the first action should be to assess the fetal heart rate to check for signs of distress.
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