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 A
Explanation
The correct answer is choice A.
Choice A rationale:
A newborn who is getting enough breast milk should wet 6 to 12 diapers per day. This is because adequate hydration, a sign of sufficient milk intake, leads to frequent urination.
Choice B rationale:
A wake cycle of 30 to 60 minutes after each feeding does not necessarily indicate the baby is getting enough milk. It could be due to other factors like sleep patterns or general health.
Choice C rationale:
A baby should not sleep at least 6 hours between feedings. Newborns need to be fed every 2-3 hours.
Choice D rationale:
While burping can be a sign of a good feeding, it does not necessarily mean the baby is getting enough milk. It’s more related to the baby’s digestion of the milk.
Correct Answer is D
Explanation
The correct answer is choice D.
Choice A rationale:
Washing the cord daily with mild soap and water is not recommended as it can delay healing and increase the risk of infection.
Choice B rationale:
Applying petroleum jelly to the cord stump is not recommended as it can create a moist environment that promotes bacterial growth.
Choice C rationale:
The diaper should be folded down to keep the cord stump dry and exposed to air, which promotes healing.
Choice D rationale:
Giving a sponge bath until the cord stump falls off is recommended to keep the area dry and prevent infection.
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