At 3 hours postpartum, a gravida 2, para 2 complains of rectal pressure and increasing perineal pain.
She is unable to void.
This woman had a low forceps delivery with a midline episiotomy and a third-degree laceration.
The fundus is firm and one fingerbreadth below the umbilicus.
Lochia is moderate, bright red and without clots.
The nurse is correct to assess further for
a hemorrhoid.
a bladder infection.
uterine atony.
a vaginal laceration or hematoma.
The Correct Answer is D
Choice A rationale
A hemorrhoid is a swollen, inflamed vein in the rectum or anus, which can cause pain and pressure, especially after the strenuous process of childbirth and pushing. While possible, the combination of increasing perineal pain, rectal pressure, and inability to void following a forceps delivery and a third-degree laceration is more indicative of a deeper tissue injury or collection of blood than an external or internal hemorrhoid alone.
Choice B rationale
A bladder infection, or cystitis, typically presents with symptoms such as dysuria (painful urination), urgency, frequency, and sometimes hematuria, often appearing later in the postpartum course. While urinary retention is a risk after birth trauma, an infection is less likely to be the immediate cause of acute, rapidly increasing rectal pressure and severe perineal pain just three hours after delivery.
Choice C rationale
Uterine atony is the failure of the uterus to contract sufficiently after childbirth, which is the most common cause of postpartum hemorrhage. The assessment states the fundus is firm and the lochia is moderate without clots, which rules out significant uterine atony as the primary issue causing the localized, intense perineal and rectal discomfort.
Choice D rationale
A vaginal or vulvar hematoma is a collection of blood in the connective tissue, often resulting from trauma during delivery, especially with forceps, episiotomy, and deep lacerations. Its rapid expansion causes severe, unremitting, localized pain, rectal pressure (from mass effect), and can lead to urinary retention by distorting the urethra, which perfectly aligns with the patient's acute symptoms. —.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Uterine cramping pain, often called afterpains, is a normal physiological process, especially in multiparous women or those who are breastfeeding. This pain is caused by oxytocin-mediated uterine contractions that help the uterus involute and compress blood vessels, which reduces the risk of hemorrhage.
Choice B rationale
A heart rate of 108 beats/minute (tachycardia) is a finding that warrants further investigation. The normal postpartum heart rate is typically 60-100 beats/minute (although mild, transient bradycardia may occur). Persistent tachycardia can be an early sign of hypovolemia due to hemorrhage, infection (sepsis), or pain.
Choice C rationale
Deep red, fleshy-smelling lochia (Lochia rubra) is the expected discharge for the first 3-4 days postpartum. The fleshy odor is normal, originating from the sloughing decidua, and indicates normal uterine healing and cleansing. An offensive odor would suggest an infection.
Choice D rationale
Diaphoresis (profuse sweating) is a normal physiological mechanism in the postpartum period. It is the body's way of eliminating the increased fluid volume accumulated during pregnancy and the excess fluid retained during labor. This is a normal process of diuresis and fluid balance restoration.
Correct Answer is C
Explanation
Choice A rationale
Newborns, especially breastfed ones, need to feed frequently, usually 8 to 12 times in 24 hours or every 2 to 3 hours, not every 4-6 hours. Frequent feeding is essential because breast milk is easily digested, and the newborn's stomach capacity is small. Delaying feedings can lead to insufficient caloric intake, potentially causing hypoglycemia, inadequate weight gain, and lower milk supply development. —.
Choice B rationale
Keeping a baby swaddled during breastfeeding can hinder feeding by restricting arm and hand movement. This restriction prevents the infant from using their hands for self-attachment or tactile stimulation, which are cues that promote effective latch and suckling. The baby should be unwrapped to allow this sensory input and maximize the opportunity for an optimal feeding experience. —.
Choice C rationale
Demand feeding or cue-based feeding, which involves feeding the infant whenever they exhibit signs of hunger (e.g., rooting, sucking, hand-to-mouth movements), is the recommended practice for successful breastfeeding. This approach ensures the baby receives adequate nutrition and stimulates the mother's breasts to produce a milk supply that matches the baby's individual needs, following the principle of supply and demand. —.
Choice D rationale
Fussiness or perceived dissatisfaction should not automatically lead to formula supplementation or switching, as this can interfere with the establishment of the mother's milk supply and the baby's ability to regulate intake. Instead, the mother should ensure a proper latch and continue to offer the breast frequently, seeking professional lactation support before introducing formula. —. ##
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