The nurse is caring for a postpartum client who is experiencing severe pain and a sensation of pressure in her perineum.
Her uterus is firm, and she has a moderate flow of lochia.
Upon inspection, the nurse discovers that a perineal hematoma is starting to form. What should the nurse assess first?

Heart rate and blood pressure.

Urinary output and IV fluid intake.

Hemoglobin and hematocrit levels.

Abdominal contour and bowel sounds.

Answer and Explanation

The Correct Answer is A

Choice A rationale

A postpartum client experiencing severe pain and a sensation of pressure in her perineum, along with the formation of a perineal hematoma, is in a potentially serious situation. The nurse should first assess the client’s heart rate and blood pressure. This is because a perineal hematoma can lead to significant blood loss, which could cause changes in these vital signs.

Choice B rationale

While monitoring urinary output and IV fluid intake can be important in the overall assessment of a postpartum client, these are not the most immediate concerns when a perineal hematoma is forming.

Choice C rationale

Checking hemoglobin and hematocrit levels can provide information about the client’s blood volume and potential blood loss. However, this would likely be done after initial vital signs are assessed and stabilized.

Choice D rationale

Assessing abdominal contour and bowel sounds would not be the most immediate concern in this situation. These assessments would be more relevant if there were concerns about postpartum complications related to the client’s gastrointestinal system.

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Correct Answer is C

Explanation

Choice A rationale

While increasing caloric intake can be beneficial for breastfeeding mothers, it does not directly address the client’s concern about decreased insulin needs.

Choice B rationale

Advising the client to breastfeed more frequently does not directly address the client’s concern about decreased insulin needs.

Choice C rationale

Breastfeeding can lead to a decreased need for insulin in some individuals. This is because lactation requires energy, and this energy demand can affect the mother’s insulin requirements.

Choice D rationale

While scheduling an appointment with the diabetic nurse educator can be helpful, it is not the immediate response to the client’s concern about decreased insulin needs.

A. Pudendal block. B. Paracervical block. C. Epidural block. D. Saddle block.

Correct Answer is A

Explanation

Choice A rationale

A pudendal block is a type of anesthesia that results in a loss of sensation confined to the vagina and perineum. It’s often used during the second stage of labor or for episiotomy repair.

Choice B rationale

A paracervical block provides anesthesia to the cervix and the lower part of the uterus, but it does not specifically target the vagina and perineum.

Choice C rationale

An epidural block provides a band of numbness from the bellybutton to the upper legs, allowing the patient to be awake and alert throughout labor. It’s not confined to the vagina and perineum.

Choice D rationale

A saddle block is a type of spinal anesthesia that numbs the inner thighs, buttocks, and area around the rectum (the “saddle” area), but it’s not confined to the vagina and perineum.

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The nurse is caring for a postpartum client who is experiencing severe pain and a sensation of pressure in her perineum.Her uterus is firm, and she has a moderate flow of lochia.Upon inspection, the nurse discovers that a perineal hematoma is starting to form. What should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A new mother, who is breastfeeding her 4-week-old infant and has type I diabetes, reports that her insulin needs have decreased since the birth of her child.What action should the nurse take?

Correct Answer is C

Explanation

Which type of anesthesia, when used with a laboring client, results in a loss of sensation confined to the vagina and perineum?

Correct Answer is A

Explanation

What is the most crucial assessment for the nurse to perform after administering epidural anesthesia to a patient who is at 40 weeks gestation?

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The nurse is caring for a postpartum client who is experiencing severe pain and a sensation of pressure in her perineum.
Her uterus is firm, and she has a moderate flow of lochia.
Upon inspection, the nurse discovers that a perineal hematoma is starting to form. What should the nurse assess first?