When reviewing the medical record of a postpartum client, the nurse notes that the client has experienced a fourth-degree laceration.
The nurse understands that the laceration extends to which area?.
Superficial structures above the muscle.
Through the anterior rectal wall.
Through the anal sphincter muscle.
Through the perineal muscles.
The Correct Answer is D
The correct answer is choice D.
Choice A rationale:
Superficial structures above the muscle refer to first-degree lacerations, which only involve the skin of the perineum and vaginal mucosa.
Choice B rationale:
A fourth-degree laceration does not stop at the anterior rectal wall. It extends through the anal sphincter and into the rectal mucosa.
Choice C rationale:
While a fourth-degree laceration does involve the anal sphincter muscle, it also includes the underlying rectal mucosa.
Choice D rationale:
A fourth-degree laceration involves the perineal muscles, the anal sphincter, and the underlying rectal mucosa.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C.
Choice A rationale:
Generalized vasospasm is not a symptom of abruptio placenta. It is more associated with conditions like preeclampsia.
Choice B rationale:
Abruptio placenta is usually associated with painful dark red vaginal bleeding, not painless bright red bleeding.
Choice C rationale:
“Knife-like” abdominal pain with vaginal bleeding is a classic symptom of abruptio placenta.
Choice D rationale:
Increased fetal movement is not a symptom of abruptio placenta. In fact, fetal movement may decrease due to distress.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
Heart rate and respiratory effort are two of the five parameters of the Apgar score. However, this choice is incomplete as it does not include all five parameters.
Choice B rationale:
Temperature is not a parameter of the Apgar score. Tone is a parameter, but this choice is incomplete as it does not include all five parameters.
Choice C rationale:
Color is a parameter of the Apgar score. However, this choice is incomplete as it does not include all five parameters.
Choice D rationale:
The Apgar score is based on five parameters: heart rate, breaths per minute (respiratory effort), irritability (response to stimulation), tone (muscle tone), and color. Therefore, this choice is correct.
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